Advanced Practice Student Clinical Request

Clinical requests are granted for one academic semester or term. Each clinical request must be submitted during the current application period.

Before applying, please check with your institution or instructor to determine if a current affiliation agreement is in place. This is a contract between Penn State Health and your institution of learning. Do not proceed further until you have confirmed a current affiliation agreement is in place.

First Name

Last Name

Phone Number

School

Clinical Program of Study

Are you a Penn State Health Employee?

If yes, provide your Penn State Health email address

Number of clinical hours requested

Clinical Request Description. Do not list course numbers.

Do you have a location preference for clinical placement?

Is there a certain provider or practice with whom you are requesting to do a clinical rotation? This is not an expected requirement for placement.

If yes, list the name of the provider, practice and location.

Requested Start Date

Requested End Date

List any previous clinical rotations you will have completed when this request begins.

Expected Graduation Date

Additional Comments

Clinical Advisor Contact Information

First Name

Last Name

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