Advanced Practice Providers (APP) Student Clinical Placement Program Interest Form

Advanced Practice Providers (APP) Student Clinical Placement Program Interest Form
Applicant Criteria

You must meet one of the following criteria:
- Employed by Reid Health
- Student of a local university
Today's Date:*

MonthDayYear
Date
Name:*
DOB:*

MonthDayYear
Mailing Address:*
Phone Number:*
Email Address:*
example@example.com
Preferred Method of Contact:*
Have you ever worked at Reid Health before?*

YesNoCurrent Employee
If yes, what Dept?*
Education Information
School:*
Projected Graduation Date:*

MonthDayYear
Date
Program:*

PANPOther (Midwife)
School Contact:*
Email:*
example@example.com
Phone: #*
Current GPA:*
School accreditation *

CCNEACENOther
Immunizations & Background check up-to-date?*
Have you have EPIC Training? If Yes, When and Where?*
Last five digits or your Student ID:*
Clinical Rotation Desired

	Specialty	# of Hours	Date Range of Rotation	School Notification Deadline	Will School Accept Urgent/Specialty Care?
1
2
3
4

Why Do You Want A Rotation With Reid Health?*
Are you now, or have you ever been a resident of Wayne County, IN?*
Please describe your Ideal Job, Post Graduation:*
May we share this interest form with Reid's Recruiting Team, so they may contact you in the future for possible career opportunities?*
Current CV/Resume

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In addition to submitting this form, please forward a current CV/Resume. This Interest Form will be reviewed by the Medical Education staff for approval. Submitting this form does not guarantee placement. It is recommended that all requests be submitted at least SIX months in advance of the rotation. Students and programs should not cold call any Reid Health sites or offices. Working outside of this process may delay placement or result in a denial.

After May 1, 2019 Reid Health will no longer be accepting students whose school is an Online Exclusive school or not accredited by CCNE or ACEN. If you currently have approved clinical hours with Reid Health and your school IS an

online exclusive school or not accredited by one of the bodies listed above, please know that Reid will honor our

commitment to you during your approved time.

Reid Health is committed to the professional development of our employees, the needs of Indiana University East students and students that live in our area, and is offering priority placement to them.

Once a rotation is approved and scheduled, the following requirements need to be completed prior to start of your clinical rotation:

Affiliation agreement must be in place between your school and Reid Health. Reid Health’s EPIC Form must be completed and received 4 hour Epic training course, if not previous trained through Reid, Community Health Network, Eskinazi or St. Francis. (If you have had EPIC training at one of these four locations, please provide a certificate of completion or your transcripts

Failure to comply may result in not being approved or a delay your start time.
Please verify that you are human*
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Advanced Practice Providers (APP) Student Clinical Placement Program Interest Form

Education Information

Clinical Rotation Desired