Experiential Learning Application

Experiential Learning Application

PLEASE NOTE, THE APPROVAL PROCESS FOR EXPERIENTIAL LEARNING APPLICATIONS MAY TAKE UP TO 14 BUSINESS DAYS.

Incomplete applications will be automatically declined. You must complete all required documentation uploads and selections on this form to submit your application.

An individual may only submit one application at a time.

Personal Information

Please complete all required fields with accurate information. Do not enter "NA" in required fields. Incomplete applications will be automatically declined.

Are you currently a Western Reserve Hospital or WRH Physicians, Inc employee?*

Yes

Are you currently a medical student?*

Yes

Medical Student Note:

To apply for Medical Student rotations, please visit https://www.westernreservehospital.org/education/medical-students and follow the instructions to complete your application.

First and Last Name*

Phone Number*

Phone

Email*

Please enter a valid email address where you can receive communication regarding placement and scheduling.

Birthdate*

Applicants under 18 years of age must have a parent/guardian co-sign their application.

Last 4 Digits of Social Security Number*

This information is required for computer account creation, if applicable.

Experiential Learning Information

Please enter information regarding your request. Note that applications may take up to 14 days to process. Western Reserve Hospital reserves the right to decline Experiential Learning applications.

Does your experience require observing in patient care areas?*

Yes

Does your experience require providing hands-on patient care?*

Yes

No, Observation Only

Requested Department or Specialty*

Select a department/specialty from the drop-down below. Only one selection is permitted.

Select

Requested Position*

Select the position/discipline of your requested preceptor from the drop-down below. Only one selection is permitted.

Select

Note:

If your experience or position is not listed, please reach out to explearning@westernreservehospital.org to inquire.

Department or Specialty Contact Name

If you have already been in contact with a WRH staff member who has agreed to your experience, please enter their name.

Is your experience required by a college program?*

Note: Colleges require affiliation agreements prior to beginning your experience. This may delay start dates.

Yes

If your program requires a minimum numbers of hours, please enter the amount below.

Proposed Start Date*

NOTE: Start and end dates may vary based on application processing time and department approval.

Proposed End Date*

Organization or School Name*

Organization or School Contact Name*

Name of program coordinator, advisor, or representative responsible for your experiential learning request.

Organization or School Contact Email*

Required Documentation for Patient Care

Upload all of the following documents or vaccination records:

Guidelines/Consent/Waiver signature page
MMR (2 doses or titers)
Varicella (2 doses, titers, or documentation of disease)
Hep B (3 doses or titers)
Flu vaccination (from current flu season)
TB test (2-step PPD, Quantiferon, or T-Spot) results from the past 5 years

Applications will be automatically declined if any of the above requirements are missing.

Required Documentation for Non-Patient Care

Upload all of the following documents or vaccination records:

Guidelines/Consent/Waiver signature page
MMR (2 doses or titers)
Flu vaccination (from current flu season)

Applications will be automatically declined if any of the above requirements are missing.

Upload all required documents below*

Drag and drop files here or

Note:

Please review your application to ensure all required documents and fields are completed. Incomplete applications will be automatically declined.

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