Please complete the 2017 MS Summer Student Nurse Externship Program Hospital Application by entering your information into the fields below.

If you have questions, or if additional follow up is needed, please contact Monica Nguyen, Project Manager, MHA Health Research, and Educational Foundation | mnguyen@mhanet.org | (601) 368.3321

* 1. Did you have a MS Summer Student Nurse Externship Program last year?

* 2. Identify the hospital/agency that is applying to offer a MS Summer Student Nurse Externship Program.

* 3. Identify the person responsible for the MS Summer Student Nurse Externship Program.

* 4. Identify an alternate person responsible for the MS Summer Student Nurse Externship Program?

* 5. Identify the nursing education program with which your facility has a current affiliation. (If more than one school is affiliated with your facility, please list all schools.)

* 6. Provide a Start Date and a Completion Date for your student nurse externship program.

Start Date
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Completion Date
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* 7. How many student nurse externs will you admit to your program in 2017?

* 8. Do you have a formal orientation in your facility for each student nurse extern?

* 9. Do you provide objectives for clinical experiences?

* 10. Do you provide objectives for orientation classes?

* 11. Do you provide a registered nurse, with a minimum of one year's clinical practice, to provide direct supervision on the unit where each student nurse extern is assigned and during the hours when the student nurse extern is working?

* 12. Is your student nurse externship program at least 320 hours in length?

* 13. Is each student nurse extern assigned at all times to a registered nurse preceptor that meets externship program criteria?

* 14. Are all preceptors fully oriented to program guidelines, clinical skills checklists, student nurse extern responsibilities, and preceptor responsibilities?

* 15. Do you have a procedure for collaborating with the school of nursing regarding clinical skills the student nurse externs can perform?

* 16. Do you have a procedure to validate clinical skills of student nurse externs prior to independent performance of the skills?

* 17. Do you have a formal job description for student nurse externs?

* 18. Do you allow student nurse externs to function as a charge nurse or team leader?

* 19. Do you obtain each student nurse extern's signed consent to release information regarding the student nurse extern's performance to the school, if requested, and to the Education Service Liaison Committee?

* 20. Do you agree to submit all evaluation materials and reports as required by the student nurse externship program guidelines?

* 21. The program coordinator has reviewed and agrees to comply with the nursing program guidelines for externship programs for students of nursing.

* 22. Please provide your information below.

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