Copy of NAU Practicum Experience Site Request Form

PRACTICUM EXPERIENCE SITE REQUEST FORM

NOTE: This request form should be submitted at least two terms prior to scheduled practicum course. Academic advisor approval and completion of major core courses are required prior to registering for the practicum.

Please complete the form to request your Practicum site (Please enter at least three locations). You will only be assigned to one site. Please note that listing your choices does not guarantee acceptance at the facility.

Complete the form below by listing facilities in order of preference.

The form will be forwarded to the Practicum Placement Coordinator for review and placement. You will be contacted via email or phone regarding placement.
*Please complete ALL fields below.

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* 1. Please complete ALL fields below:

Name: *

Student ID: *

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Email Address: *

Phone Number: *

Please select the Anticipated QUARTER and YEAR you will enroll in the practicum course:

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* 2. Anticipated Quarter:

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* 3. Anticipated Year:

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* 4. Which practicum course will you be enrolling in?

HT2300D Healthcare Coding

HT2500D Health Information Technology

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* 5.
Do you wish to complete your practicum online?

The online option is a virtual practicum where the student completes the required hours through online/virtual activities instead of going to a physical site to complete their hours. This option is available to students enrolling in the HT2300D Healthcare Coding Practicum and HT2500D Health Information Technology Practicum. Students enrolling in the HT2500D Health Information Technology Practicum who select the virtual option will be contacted by the Practicum Coordinator for virtual practicum approval/confirmation.

Students enrolling in the HT2500D Health Information Technology Practicum are required to complete some hours on site.

Yes

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* 6. Disclosure: Select all of the following that may apply:

There are no family members or friends working at any of the facilities listed below.

Family members and/or friends work at one or more of the facilities listed below.

I currently work at one of the facilities listed below.

If you have family members and/or friends working at one or more of the facilities listed below, please list them below:

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* 7. Please list your availability (days of week and times) to complete your practicum hours onsite. Please type N/A in the other box if you have chosen a virtual option.

	Early Morning	Late Morning	Afternoon	Late Afternoon	Evening
Sunday	Sunday Early Morning menu	Sunday Late Morning menu	Sunday Afternoon menu	Sunday Late Afternoon menu	Sunday Evening menu
Monday	Monday Early Morning menu	Monday Late Morning menu	Monday Afternoon menu	Monday Late Afternoon menu	Monday Evening menu
Tuesday	Tuesday Early Morning menu	Tuesday Late Morning menu	Tuesday Afternoon menu	Tuesday Late Afternoon menu	Tuesday Evening menu
Wednesday	Wednesday Early Morning menu	Wednesday Late Morning menu	Wednesday Afternoon menu	Wednesday Late Afternoon menu	Wednesday Evening menu
Thursday	Thursday Early Morning menu	Thursday Late Morning menu	Thursday Afternoon menu	Thursday Late Afternoon menu	Thursday Evening menu
Friday	Friday Early Morning menu	Friday Late Morning menu	Friday Afternoon menu	Friday Late Afternoon menu	Friday Evening menu
Saturday	Saturday Early Morning menu	Saturday Late Morning menu	Saturday Afternoon menu	Saturday Late Afternoon menu	Saturday Evening menu

Other (please specify)