Community Requests for Nursing Student Health Assessments

Full Name *

Company/Organization *

Email *

Phone Number

Phone

Name of Event *

Date of Event *

Time of Event *

Will this be a recurring event? *

Yes

No

How many people are you expecting to attend your event? *

Please describe the clinical or health promotion activities that you’d like our faculty and nursing students to assist with. *

How many nursing students do you need? *

Do you have your own equipment and patient education materials (for example, blood pressure cuffs, hand-outs on high blood pressure) or would you need the CON to provide these? *

For screening events, please describe your referral network for those who screen positive.

*

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