Allied Health Student/Trainee Request

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Allied Health Student/Trainee Request Form

Please provide the name and contact information of the person filling out the form:

First Name:

Last Name:

Email Address:

Are you able to accommodate an enriched learning experience for all the ETSU medical students and residents assigned to your clinical department?

Yes

_________________________________________________________________________________________________________________________________________

1. Name of the Student /Trainee:

First Name:

Last Name:

2. Area of Training:

3. Department:

4. Student/Trainee Institution:

5. Student/Trainee Training Program:

6. Identified Supervisor:

7. Date of Experience:
Please select below the starting Date and the ending date:

Begin Date:

End Date:

7a. Hours Per Week:

7b. Total number of students/trainees the identified supervisor will oversee during these dates of the experience:

8. Goals and Requirements:

9. Onboarding requirements met?

Yes

10. How will the student/trainee be included in teaching rounds, didactics, and other aspects of team-based practice?

11. How will the student/trainee be evaluated and feedback communicated?

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