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FIELD EXPERIENCE SITE INFORMATION FORM

Student Name: Student ID#:

Program of Study/Degree:

Where do you plan to complete your field experience hours?

Site Name:

Address 1:

Address 2:

City: State: Zip:

What type of facility is this?

What is the primary population type?

What is the unit type, if applicable?

What types of patients are seen in this facility?

How does this site experience meet your course objectives?

Student Signature: Date:

Note: Students to provide this form to both OFE and into their classroom according to this schedule: RN to BSN during week 1 of capstone; MSN during week 1 of the Practicum/Clinical or DNP during first week of DNP 805. DNP students also provide preceptor CV.

16CON0003

1. Student ID:
2. Student Name:
3. Program of Study/Degree:
4. Site Name:
5. Site Name 1:
6. Site Name Address1:
7. Site Name Address2:
8. City:
9. State:
10. Zip:
11. Preceptor's Name:
12. Preceptor's Title:
13. Preceptor's PH:
14. Preceptor's Email ADD:
15. Preceptor's Credentials:
16. Signature 1:
17. Date 1: