EXCELSIOR NUR448 2019 January Module 3 A2 SLEC Request and Approval Form Submission Latest

NUR448  COMMUNITY HEALTH NURSING  CARING FOR THE PUBLIC'S HEALTH

Module 3 A2 SLEC Request and Approval Form Submission

Complete and submit the Service Learning Experience Clinical Request & Approval Form to your NUR448 Faculty Instructor for final approval.

You will submit this form to your NUR448Faculty Instructor during Module 3/Week 5 through the M3A2: SLEC Form Submission assignment dropbox.

Please note: final approval is required prior to contacting and setting up SLEC times with the agency.

All sections MUST be filled out.

Student Name: _______________________________________________________________________

Name of agency/organization/resource where SLEC will take place: _____________________________________________________________________________________

Name & title of contact individual/mentor at agency: _____________________________________________________________________________________

Contact information for SLEC site: _____________________________________________________________________________________

                                Street address                                                                   City/State/Zip Code

_____________________________________________________________________________________

                          Phone number                                                   email address

Vulnerable PopulationServed: __________________________________________________________ _

Health People 2020 Goal and Objective addressed by agency: _____________________

____________________________________________________________________________________

Give a brief description of the agency&the services provided by this agency: ____________________

_____________________________________________________________________________________

___________________________________________________________________________________

Activitiesengaged to meet course outcomes: _______________________________________________

__________________________________________________________________________________________________________________________________________________________________________

Faculty Instructor’s Signature                                                                                Date of Approval

If not approved reason: _______________________________________________________________

___________________________________________________________________________________