APP Clinical Rotation Request Form

This form is to be completed by CRNA, NP, PA, RNFA, and MSN* students. This form is to be completed for each clinical rotation request for each preceptor/specialty.

*If you are in an Alternate Entry MSN program and do not have an RN license this program is not for you. Please contact TXUndergradnursing@ascension.org


Submission deadlines:

  • With a Preceptor
  • NO LATER than SIX (6) weeks prior to the rotation start date specified on your application.


  • Without a Preceptor
  • NO LATER than TWELVE (12) weeks prior to the rotation start date specified by you on your application.


**LATE submissions received past the submission deadlines will be automatically denied.


Approval Requirements

  1. APP Rotation Request Form Submitted
  2. Resume Attached
  3. RN License Attached (not required for PA's)
  4. Preceptor Identified and secured - confirmed to be employed by an Ascension affiliated provider group
  5. Rotation site MUST be an Ascension Site
  6. Attestation form must be signed and received from College or University
  7. Annual 'Terms of Use' agreement must be completed for EHR access (even if you are a current employee)
  8. Annual MyLearning - HIPPA compliance modules completed (for all non Ascension employed applicants)


Filling out the form Without a Preceptor

If you do not have a preceptor at this time, place "Needs Preceptor" in the preceptor name field and leave all other preceptor information fields blank. Securement of a preceptor is ultimately the responsibility of the student. Ascension does not secure preceptor matches. If a preceptor is not secured within THREE weeks prior to the clinical rotation start date specified, the rotation will be closed out.


Rotation Close Out dates:

ALL applications, regardless of whether or not a student has secured a preceptor, that have NOT been closed out and approved within 2 weeks AFTER the anticipated start date listed on the application will be closed out as incomplete. Please ensure you are actively working with your school to provide all necessary documentation needed by both the school and Ascension to complete a timely approval.


At the bottom of this form, please be sure to select the box, 'Send me a copy of my responses' to receive an email with your submission information for your records. *If any information entered in this form is found to be invalid, the request will be denied.


Reminder: All students participating in the program are required to comply with the rules and regulations of the Facility while on premises and to comply with the requirements of all federal, state and municipal laws, ordinances and regulations, including but not limited to those regarding the confidentiality of information in records maintained by Facility.


A student will be removed for violating any law, ordinance or rules and regulations of the Facility; has disclosed information that is confidential by law; or has engaged in conduct that disrupts the activities carried on by the Facility or threatens the safety or Facility personnel or patients.


PLEASE NOTE: This is only an intake form and is NOT an automatic approval to begin your rotation.

 

Terms of Use Agreement: Digital Access

Click on the link below to review the Ascension policies related to computer use and data access. Upon completion, please return to your application to complete next steps.

TERMS OF USE AGREEMENT


 

Enter 'Todays Date' to attest to your understanding and consent of the Terms of Use Agreement.

 

Personal Information

 
 
 
 
mm/dd/yyyy
 

Please just enter the LAST 4 digits of your SSN

 
 

Professional Email Address: This email will be used for ALL communication pertaining to this request and any future employment opportunities so please use the email address you check the most frequently.

 
Phone
 
Phone
 

** PA Students - Choose N/A


If you are in an Alternate Entry MSN program and do not have an RN license this program is not for you. Please contact TXUndergradnursing@ascension.org


TEXAS LICENSED Participants ONLY. If you do not have a TX RN license or a License in a state that participates with Texas as a Compact state we cannot permit you to complete a rotation within Ascension Texas. Please review the BON website for further details on compact state participants.

 
 
Phone
 
 

College or University Information

 

If your school is not in this list please choose 'Other'.

 
 

Certificate option applies to those students who already have an advanced degree in nursing and are receiving additional education for certification (e.g. Post Master's/Doctorate APRN Certificate, Post Master's Administration Certificate, etc.)

 

Ascension must be made aware when Students are completing research or project based work.

 
 
mm/dd/yyyy
 

Please list your school Clinical Placement Coordinator, NOT your clinical course instructor.

 

XXX-XXX-XXXX

Phone
 
 

Rotation Specific Information

 
 

Please indicate the date of the first day you will actually be at your clinical rotation site. If you do not have a preceptor, use your clinical course start date.

 
mm/dd/yyyy
 

Please ensure this is the LAST date you will be on site. This date determines EHR and Badge access end dates.

 
mm/dd/yyyy
 

Please indicate which days of the week you will be on site with your preceptor. If you do not have a preceptor, please list the days you are available to complete rotation hours.

 

If more than one specialty, an additional form must be completed. If you do not have a preceptor, please be very specific in the specialty you are seeking.

 

Inpatient, Outpatient/ Clinic Based, or Administrative

 

Only include the hours needed for this semester, preceptor, site and specialty specifically.

 

If more than one preceptor, an additional form must be completed.

 

Attachments

 

Please attach a current copy of Your resume and Your license verification. Both of these documents are required to Approve your rotation. Please name files LastName.FirstName.Resume and LastName.FirstName.License and save in PDF format.


For license verification, go to: (https://www.nursys.com/LQC/LQCSearch.aspx) and search your license by the 6 digit license number, license type, and state. Your results will appear at the bottom of the screen. Click 'View Report', then click 'Download Report', choose 'Download full report' then click 'Download'. The file will appear in the Downloads folder on your computer which you will then rename and upload here. BON Certificates are NOT Acceptable.


My Learning Certificate:

If previously completed, upload myLearning Module Completion Certificate ( ** upload the following form if you have already done these items within the past 12 months).


Badge Photo:

Please UPLOAD a HEADSHOT photo for the badging office. Badge photos MUST include:

  • Image of you from the shoulders/chest to the top of your head
  • Normal to bright lighting
  • Clear face free of emojis, filters, excessive makeup or other objects obscuring your identity
  • Plain, light and/or bright background
  • Clothing without graphics or patterns
  • Clothing with conservative neckline


This photo will be used to make your badge ahead of your rotation. If your photo fails to meet these criteria, the creation of your badge WILL be delayed and you will be required to resubmit.


MSN / DNP / PHD Students:

Upload your CNO Site approval letter or email communication providing official approval to complete your project work at the site listed in this application

Drop your files here
 

Employment Information

This information will be shared with Ascension Talent Acquisition, along with the CV or Resume you upload.

 

If unemployed, enter 'Unemployed' or 'N/A' *Employment is not a requirement for approval.

 
 
 

By selecting "YES" you consent to receive text messages and/or emails, at the phone number and email provided within this student application, from Ascension regarding employment opportunities.

 

Please include any additional information that may be helpful to Academic Administration in processing your request.