KPWA Nursing Student Placement Request Form

Please use this form for student placement requests for MA and RN students at Kaiser Permanente of Washington. Please note: at this time, we are unable to accommodate ARNP & LPN placements.


We will review requests based on the calendar below and notify you of placement at least 1 month prior to the requested start date.


Rotation Start Date (Desired)        Request Due Date

January, February, March                     September 30

April, May, June                                    January 31

July, August, September                        March 31

October, November, December             June 30


Please complete ONE entry per student. To request multiple student placements (10+), please email KPWA-StudentPlacements@kp.org for the multiple students template.


Other Areas: for Physician/Physician Assistant (PA) shadowing, please use this link.


Prior Submissions: to view prior submissions and status, use this link. You must be logged into smartsheet with the email address used for the submission.

Contact Information

Does your school have a current affiliation agreement with Kaiser Permanente of Washington?


If not, please contact our team at KPWA-StudentPlacements@kp.org.

Please provide a name for follow-up

Please provide the school contact's role/title, for instance, Nursing Practicum Coordinator

Please provide the school contact email

Phone

Placement Request

Student Type*

Please specify the student type being requested (i.e. MA, RN, etc.)

Program Year (not required for MA or ARNP students)*

What year of school will the student be completing during their placement?

Please indicate preferred name if different from legal name

If a preceptor/staff member has agreed to let you shadow them, please enter their name here. For PA/Physician shadowing, please visit this link.

Is this request for the student to be observation-only?

Note: observation students will not be given computer access. If access is needed, please do not select observation.

Geographic/Clinical Preferences

Preferred Geographic Area - 1st choice*

Please select the preferred geographic location for this request. For more information, see this full list of KPWA facilities.

If applicable, please provide a 2nd choice geographic area (Optional)

Select
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Please provide any further information about preferred locations (i.e. limitations, preferences).

Clinical Area (Preferred)*

Please indicate the type of clinical experience being requested (i.e. Urgent Care, Adult Primary Care, etc.). You may add details in the section below.

If applicable, please provide a 2nd choice clinical specialty area (Optional)

Select
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Please provide any further information about preferred specialty areas and/or any prior related experience (i.e. current Surg Tech, PCT, etc.)

Please provide the date when you anticipate the student will begin their placement

Please indicate the number of hours the student must complete

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