Optum CO
Student Placement Request Form

Instructions: Please fill out as much information as you can and submit only once. We will review your request and reach out if there are available preceptors. Approved requests may take 1-2 weeks for completion. Thank you.

Today's Date

MM/DD/YYYY

mm/dd/yyyy

Name of Person Filling Out Form

Student Information

Student's Full Name

Last, First

Student's Phone Number

Phone

Student's Email Address

School Email is Preferred

Are you an Optum/UHG Employee?

YES

Student Coordinator's Email Address

If Applicable

School/Program Information

Which School do You Attend?

Select "Other" if your school is not listed.

Select Your Credentials or Program Type

Rotation Information

If known, please input ONE separate entry PER rotation, preceptor or clinic. Example: Entry 1: Dr. Jones 1-21 to 2-21 at ABC Clinic; Entry 2: Dr. Smith 2-22 to 3-22 at ABC Clinic.

Type of Rotation/Externship

Full Clinicals

Shadow Only

Other (specify in comments)

Rotation/Externship Start Date

mm/dd/yyyy

Rotation/Externship End Date

mm/dd/yyyy

How Many Hours are Required for Your Rotation/Externship?

Select the Preferred Specialty for this Rotation.

Select which geographic area(s) you prefer to be placed.

State

Are you willing to travel outside of your selected areas?

YES

Have you Identified a Clinician to Work With?

YES

Additional Information

Please list any information that can help the Optum team better coordinate placement for you.

Upload Your Resume or CV (Optional)

Drop your files here

Send me a copy of my responses

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Optum COStudent Placement Request Form

Student Information

School/Program Information

Rotation Information

Additional Information

Optum CO
Student Placement Request Form