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1. Requestor Name:

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2. Requestor Email:

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3. Requestor Phone:

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4. Requestor School/Hospital

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5. What type or placement?

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6. If Nursing Student, please select type:

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7. Year of Study

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8. Year of Residency

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9. Total number of students/residents needing placement.

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10. Number of students/residents per rotation.

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11. Type of rotation:

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12. What course or clinical rotation is this experience part of?

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13. Competencies/Milestones or areas of rotation needing to be met. (Multiselect)

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14. Supervision Requirements

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15. Duration of Rotation

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16. What is the desired schedule in terms of hours and days/weeks for this experience?

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17. Preferred/anticipated start date:

Date

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18. Requested Geographic Location: https://dph.georgia.gov/document/document/georgia-public-health-district-map/download

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19. Attach supporting documents e.g., guidance, competencies, grant funding information.

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 100% of survey complete.

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