2015 Summer Student Nurse Externship - Hospital Application

Please complete the 2015 MS Summer Student Nurse Externship Program Hospital Application by entering your information into the fields below.

If you have questions, or if additional follow up is needed, please contact Dawn Ard, Project Manager, MHA Health, Research, and Educational Foundation | dard@mhanet.org | (601) 368.3321

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* 1. Did you have a MS Summer Student Nurse Externship Program last year?

Yes

If Yes, how many of the Externs did you hire upon student graduation?

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* 2. Identify the hospital/agency that is applying to offer a MS Summer Student Nurse Externship Program.

Facility Name

Address

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* 3. Identify the person responsible for the MS Summer Student Nurse Externship Program.

Name

Title

Phone

Fax

Email Address

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* 4. Identify an alternate person responsible for the MS Summer Student Nurse Externship Program?

Name

Title

Phone

Fax

Email Address

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* 5. Identify the nursing education program with which your facility has a current affiliation. (If more than one school is affiliated with your facility, please list all schools.)

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* 6. Provide a Start Date and a Completion Date for your student nurse externship program.

Start Date

Date

Completion Date

Date

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* 7. How many student nurse externs will you admit to your program in 2015?

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* 8. Do you have a formal orientation in your facility for each student nurse extern?

Yes

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* 9. Do you provide objectives for clinical experiences?

Yes

If yes, please copy/paste your clinical objectives below. Or send them via email to dard@mhanet.org.

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* 10. Do you provide objectives for orientation classes?

Yes

If yes, please please copy/paste your orientation objectives below. Or send them via email to dard@mhanet.org.

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* 11. Do you provide a registered nurse, with a minimum of one year's clinical practice, to provide direct supervision on the unit where each student nurse extern is assigned and during the hours when the student nurse extern is working?

Yes

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* 12. Is your student nurse externship program at least 320 hours in length?

Yes

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* 13. Is each student nurse extern assigned at all times to a registered nurse preceptor that meets externship program criteria?

Yes

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* 14. Are all preceptors fully oriented to program guidelines, clinical skills checklists, student nurse extern responsibilities, and preceptor responsibilities?

Yes

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* 15. Do you have a procedure for collaborating with the school of nursing regarding clinical skills the student nurse externs can perform?

Yes

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* 16. Do you have a procedure to validate clinical skills of student nurse externs prior to independent performance of the skills?

Yes

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* 17. Do you have a formal job description for student nurse externs?

Yes

If yes, please copy/paste the job description below. Or send it via email to dard@mhanet.org.

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* 18. Do you allow student nurse externs to function as a charge nurse or team leader?

Yes

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* 19. Do you obtain each student nurse extern's signed consent to release information regarding the student nurse extern's performance to the school, if requested, and to the Education Service Liaison Committee?

yes

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* 20. Do you agree to submit all evaluation materials and reports as required by the student nurse externship program guidelines?

Yes

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* 21. The program coordinator has reviewed and agrees to comply with the nursing program guidelines for externship programs for students of nursing.

Yes

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* 22. Please provide your information below.

Summer Student Nurse Extern Program Coordinator

Date