Request for Nursing Program Clinical Placement
at Penn State Health
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
Please select Penn State Health hospital:
Please select...
Penn State Health Hampden Medical Center/Penn State Health Holy Spirit Medical Center
Penn State Health Lancaster Medical Center
Penn State Health Milton S. Hershey Medical Center
Penn State Health St. Joseph Medical Center
Pennsylvania Psychiatric Institute (PPI)
Is this a school required clinical experience or an exploration shadow experience?
Please select...
School required
Exploration shadow
Number of clinical hours requested:
Specific days of the week 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