Undergraduate Preceptorship Need for Placement

This form should be completed my the School or University seeking undergraduate preceptor placement within Cone Health. One form should be submitted per placement request. For example: If you are requesting 1 placement for pediatrics and then another for Labor and Delivery, two separate forms should be completed.

If any questions or concerns arise, please contact the Clinical Education Coordinator: Nick Comeau, MSN, RN, CCRN, TCRN, CPN at Nick.Comeau2@conehealth.com

Question Title

* 1. Name of School or University

Question Title

* 2. School of Nursing Clinical Coordinator Contact Information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Question Title

* 3. Specialty Request Area

Adult ICU

Adult Stepdown

Adult Acute/Medical-Surgical

Pediatrics (Pediatric Acute Care and Pediatric ICU)

Neonatal (NICU, Mother/Baby)

Labor & Delivery

Emergency Department

Rehabilitation

Behavioral Health/Psychiatric-Mental Health

Other (please specify)

Question Title

* 4. Specific Campus Request

Moses H. Cone Memorial Hospital, Greensboro

Wesley Long Hospital, Greensboro

Annie Penn Hospital, Reidsville

Women's Hospital, Greensboro

Behavioral Health Hospital, Greensboro

Alamance Regional Medical Center, Burlington

Undergraduate Preceptorship Need for Placement

Question Title

* 1. Name of School or University

Question Title

* 2. School of Nursing Clinical Coordinator Contact Information

Question Title

* 3. Specialty Request Area

Question Title

* 4. Specific Campus Request

Question Title

* 5. How many students are you seeking placement for this specific clinical/specialty area?

Question Title

* 6. What is the intended date range for this precepted clinical rotation?