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). Since a signature is required, we cannot accept this form via e-mail. This form may be sent via mail or fax.
Student Clinical 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 Tracy Blair (MS #600) or Martha Kliebenstein (MS #600).
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 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 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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