Physician Assistant/Nurse Practitioner Student Clinical Request
Clinical Program of Study
Are you a Penn State Health Employee?
If yes, where do you work?
Is there a specific Provider you are requesting?
If yes, list the name, credentials and clinical department
If this Provider is not available, would you accept another?
Number of Clinical Hours Requested
Describe the criteria of your request (Ex.: Type of clinical experience, but do not list objectives)
60 character limit: List clinical area or specialty only.
Requested Start Date
Requested End Date
What semester are you applying for?
Clinical Advisor Contact Information:
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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