Request for Nursing Program Clinical Placement
at Penn State Health Milton S. Hershey Medical Center
Your Contact Information
First and last name:
Phone number:
Email address:
About You
Your school name:
Clinical program of study:
Please select...
LPN
ADN
BSN
MSN
DNP
Other
Enter your other clinical program of study:
Are you currently a Penn State Health employee?
Please select...
Yes
No
What area do you work in?
Your Request
Number of clinical hours requested:
Describe the criteria of your request: (Ex: Inpatient, Outpatient/Clinic, ED, OR, Leadership)
Requested start date:
Requested end date:
Specific preceptor or unit type requested?
Yes
No
Enter your request:
Clinical Contact from your School of Nursing -
First and last name:
Email address:
Phone number:
Clinical requests are granted for one academic semester or term. A continuation of a request requires another request form to be submitted and approved. Requests must be submitted at least two months prior to the requested start date.
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Contact Information