Student Forms

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.

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

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.

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 feedback to Tracy Blair (MS #600) or Martha Kliebenstein (MS #600); information will be shared with the specific unit.

 Back to Student Orientation Materials.