Faculty Forms                                         

All schools of nursing requesting nursing student placement at Children's Hospital of Wisconsin must use the following forms. Requests will not be processed if information is received in an alternative format.

Nursing Student Placement Request Form for clinical groups
This is the first step to requesting clinical group placement. This form may be sent via email, or fax.

Nursing Student Placement Request Form for precepted students. Filling out this form is the first step to requesting a one-on-one precepted experience for a last semester BSN or ADN student. This form may be sent via email or fax.  Please refer to Children's Hospital of Wisconsin unit profiles.

Nursing Student Schedule Form. This form will help our staff and units have a clear picture of when students are on the units.  Please fill this form out each semester and submit it to Diane Dooley.

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 email. This form may be sent via mail or faxed to Diane Dooley at (414) 266-5731.

Student Roster 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.

Student Information Sheet
This form can be used for undergraduate nursing students participating in a senior preceptorship. This form should be submitted with the student placement request form. Completed forms should be sent via email to Diane Dooley.

Student Clinical Site Evaluation:  https://www.surveymonkey.com/s/chwsitesurvey

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). This form is to be mailed, faxed (414) 266-5731 or scanned via email to Diane Dooley.

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 emailed to the appropriate contact person. Please refer to the Alternative learning experience listing.

Alternative Student Objectives and Evaluation Form
The first page 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 staff who works with the student at the alternative site. The second page should be returned to the clinical instructor. This form can be used by the student to evaluate their alternate site experience and for the student to evaluate the staff who worked with them during this experience. Please forward any important feedback to Tracy Blair (MS #600) or Martha Kliebenstein (MS #600) to relay back to the specific unit.

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