Advanced Practice Provider & Nursing Graduate Student Clinical Placement Form

Thank you for your interest in Premier Health. We are excited to help you on your academic journey.

Please complete the following form: all fields are required.

If you need placement for more than one clinical rotation in a semester, please submit one form for each rotation.

Premier employees are given priority placement. Student placements are not guaranteed.

Full Name *

Email Address *

School Name *

Program Type *

Date Preceptor Information is required by school *

Are you currently a Premier Health employee? *

Premier employees are given priority placement.

Have you found a preceptor who has agreed to the requirements of your clinical experience?

Name and credentials of preceptor

Type of clinical experience needed *

i.e. Women’s Health, Pediatrics, Mental health, Acute care, etc.

Practitioner Types

Choose all types of disciplines that would be acceptable.

Exact Dates of Clinical experience

Begin date *

End date *

Number of hours needed *