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:

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

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

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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.

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