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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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