Forms
All schools of nursing requesting nursing student placement at Children's Hospital must use the following forms. Requests will not be processed if information is received in an alternative format.
Nursing Student Placement Request Form
This is the first step to requesting a student placement. This form is used for clinical and preceptorship requests. This form may be sent via e-mail, or fax. Please refer to Children's Hospital of Wisconsin Unit Profiles.
Student Placement Certification Form
This form certifies that all Children's Hospital of Wisconsin health, OSHA and background check requirements are met. Since a signature is required, we cannot accept this form via e-mail. This form may be sent via mail or faxed to Diane Dooley at (414) 266-5731.
Student Information Sheet
This form (attachment to Exhibit A of program agreement) lists each student, patient care area and dates of experience. This form is to be sent with the Student Placement Ceritification Form.
Privacy and Confidentiality (HIPAA) Form
All students and faculty spending time at Children's Hospital of Wisconsin must sign and date the confidentiality form (attachment to Exhibit A of program agreement). Since a signature is required, we cannot accept this form via e-mail. This form may be sent via mail or fax.
Alternative Learning Experiences
Alternative Learning Experience Request Form
This form is used for clinical students currently conducting a rotation at Children's Hospital of Wisconsin, but who would like a one-time alternative learning experience on another unit/area. This form is to be mailed, faxed or e-mailed to the appropriate contact person. Please refer to the Alternative learning experience listing.
Alternative Student Objectives and Evaluation Form
The top portion of this form should be printed out and completed by the student prior to attending an alternative/observational experience. The bottom portion is to be completed by the preceptor who works with the student at the alternative site. The form should be returned to the clinical instructor.
Guidelines for Selective Experiences
Student Alternate Site Evaluation Form
This form can be used by the student to evaluate their alternate site experience and for the student to evaluate the preceptor who worked with them during this experience. Please forward any important feedback to Jeanne Braby (MS #6620) or Martha Kliebenstein (MS #600) to relay back to the specific unit.
Student Site Evaluation Form
This form is used for students to evaluate Children's Hospital of Wisconsin's clinical sites. Please print out this form for students to complete. Ask students to complete the form and return to the clinical instructor at the end of the clinical rotation. Completed forms should be sent to either Jeanne Braby (MS #6620) or Martha Kliebenstein (MS #600).
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