APP Clinical Rotation Request Form

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

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

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

Personal Information

First Name*

Last Name*

DOB*

Social Security Number*

Please just enter the LAST 4 digits of your SSN

Sex*

Select

Email Address*

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.

Mobile Phone Number*

Phone

Alternate Phone Number

Phone

Do you currently have a nursing license?*

** 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.

Select

What is your six-digit nursing license number?*

Are there any stipulations on your license?*

Applicants CANNOT have "restrictions" on their license. All applicants with license restrictions will be denied.

Select

Emergency Contact Name

Emergency Contact Phone Number

Phone

Emergency Contact Relation

Select

College or University Information

School Name*

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

Select

Please provide the name of your school or University

This is only needed if your school was not listed on the drop down menu provided previously and you chose 'Other' for your school name

University Program*

Select

Program Level*

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.)

Select or enter value

Is this a Clinical Rotation or Research/Project based rotation?*

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

Select or enter value

Provide a brief descrition of the Research Based project you are seeking to complete within Ascension Texas*

Has this project been approved by the Site CNO where the work will take place?*

All research projects need to have prior CNO site approval. If you do not have CNO Approval yet please click on the link below to view who you must contact in order to receive approval. Once approval is received please upload it to your application or email academicadmin@ascension.org.

CNO Contact Information

Select

Provide the name of the CNO approver for your Project*

All MSN, DNP, and PHD projects will require formal CNO approval. Indicate who was the approver for your project. You will also need to upload documentation of this approval in the form of a letter or email of approval at the end of this application.

TITLE of Upload: "CNO Approval Documentation"

A member of the Ascension Academics team will also be connecting with you regarding the IRB and SAT process for this project work.

PA License #

NPI #

DEA #

Graduation Date*

School Program Coordinator Name*

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

School Program Coordinator Phone Number*

XXX-XXX-XXXX

Phone

School Program Coordinator Email Address*

Rotation Specific Information

How did you hear about clinical rotation opportunities with Ascension?*

Select

Clinical Experience Start Date*

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.

Clinical Experience End Date*

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

Days of the Week at Rotation Site*

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.

Select

Specialty Rotation Needed*

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.

Select

What will be the primary setting of your experience?*

Inpatient, Outpatient/ Clinic Based, or Administrative

Select

How many hours do you need?*

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

Do you have a preceptor?*

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

Select

What type of professional are you authorized to work with?*

Please select all credentials that apply. (EX: Some NP programs only allow students to work with NPs, not MDs or DOs.)

Select

How many years of experience does your preceptor have?*

If you do not have a preceptor, how many years of experience must an approved preceptor have?

Select

Preceptor Name*

If you do not have a preceptor, enter 'Need Preceptor'

Title*

Provide the credentials for your preceptor

Select or enter value

Preceptor Employer*

Preceptors may be employed by Ascension Seton, Ascension Providence, University Physicians Group, Seton Family of Doctors or a third party such as Pediatrix or US Acute Care Solutions (USACS) to name a few. Please verify with your preceptor.

Select

Preceptor Phone Number*

Phone

Preceptor Email Address*

Rotation Site Name*

If your primary site includes a Clinic, Primary Care, or Specialty Care site please choose "Other" and type out your Clinic name in the field below. If you will be rotating at more than ONE site with your identified preceptor please complete a NEW rotation request for each additional site.

Select

Other - Clinic/Primary Care/Specialty Care Location Name*

Rotation Site Address: Street, City, Zip*

Attachments

Resume and License Verification / Badge Photo*

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

Drag and drop files here or

Employment Information

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

What is your current position?*

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

Are you currently an Ascension Employee (Seton or Providence)?*

Select

What is your employee username?*

The username used to login to computers on site.

At which site are you located?*

Did you move to the area to work for Ascension (Seton or Providence)?*

Select

What was your home State?*

Select

Do you wish to work for Ascension as an APP upon completion of your program?*

Select

What is your prefered specialty?*

Select

Which location do you prefer?*

If you do not have a preference enter 'Open to all Opportunities'

Desired Employment Start Date*

This date should be AFTER you become board certified.

Consent for Employment Opportunities*

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.

Yes

Comments

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

Send me a copy of my responses

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