Practicum Application

Part 1: To Be Completed By Applicant (use one form for each requested clinical experience)

First Name *

Middle Initial

Last Name *

Date of Birth *

Last 4 digits of SSN *

CURRENT LOCATION

Home Address *

Address Line 2

City *

State *

Zip Code *

Daytime Phone *

Cell Phone: *

Email Address *

Are you fluent in Spanish? *

Yes

No

Are you a MetroHealth Registered Nurse? *

Yes

No

If yes, what is your employee ID number?

OHIO LICENSE INFORMATION

RN License Number *

CURRENT SCHOOL INFORMATION

School Name *

Part 2: I Would Like to Apply for the Following Semester and Year

Semester *

Fall

Spring

Summer

Year *

Date Practicum Will Begin * +

Date Practicum Will End * +

Number of Practicum Hours Required *

What degree are you pursuing? *

RN-BSN

MSN

DNP

PhD

If pursuing MSN, please list your program track (i.e. nursing education)

Please attach program requirements here:

Hours of practicum experience being requested *

Have you identified a MetroHealth preceptor? *

Yes

No

Preceptor Name *

Preceptor Department *

Preceptor Phone *

Preceptor Email Address *

Part 4: Faculty Contact Information

School/Clinical Coordinator Name *

Coordinator Email Address *

Coordinator Phone *

Your school will need to send a letter of verification of the following:

The student is in good standing
The student possesses an unencumbered and current Registered Nurse License in the state of Ohio
Possesses a current BLS certification
*Has a valid and clear background check on file at the school (BCI/FBI within 1 year)
Has up to date vaccinations including TB, COVID-19 vaccine, and influenza vaccine (Oct-Apr)
*Clean and current 10-panel drug screen within 1 year

*MetroHealth employees are exempt from asterisk points

Please have your school send a signed verification letter from the program director attesting to all items above to NursingClinicals@metrohealth.org