Nursing 474 Clinical Request form
Which day of the week do you prefer for your assigned 474 clinical day. This day you will spend 8 hours in a public health clinical setting. We will use the information provided to make your placement even if you registered for another day. *
Either Day is OK
There are some important considerations for the first three weeks of school. How you fill out this form will determine your clinical placement. Include all the information you feel is important to help make the agency selection.
Week 1: All students will need to be available to orient to the Community Health Nursing Clinical both Wednesday and Thursday of the first three weeks of school. Please keep both days open. We will work with the N484 team to coordinate your clinical days.
Which city will be your place of residence during the semester?
Can you converse in a language other than English? If so, please specify which language.
Please describe any previous community, public or home health experience
Please choose 3 of the clinical placement options listed below. Public health agencies are located in the counties listed. Other options may be limited to certain geographic areas. You will have the opportunity to indicate your first choice later. *
Butte County Public Health
Glenn County Public Health
Sutter County Public Health
Yuba County Public Health
Tehama County Public Health
Placer County Public Health
Nevada County Public Health
Shasta County Public Health
Colusa County Public Health
Yolo County Public Health
Home Health Agency
Agencies for Prenatal education (such as Better Babies)
I will list my preferences and explanations below.
We will do our best to match your clinical requests. Please remember that the agencies listed are subject to change.
Please indicate the most important clinical request option. For example if you need to take a class on Thursday am...put the day of the week as most important.
Day of the week
Type of Experience
Please list your first choice for clinical placements. You can write in a specific agency. If you have a relationship with this agency, please describe that relationship. Keep in mind that some placements are only available on certain days and in certain locations. If we don't have an existing contract with the agency you may not be able to complete your rotation there.
PLEASE REMEMBER in addition to working at the clinical agency you will have the opportunity to participate in a community aggregate project. The aggregate projects are usually a group projects involving 2-3 students and make up 40 hours of your clinical time. plan time in your schedule for these additional 40 hours.
Please list any other information that may be helpful to faculty when assigning your public health nursing clinical placement
In order to participate in the N474 Clinical Practicum students must have provided the School of Nursing Office with all necessary immunization records, proof of automobile insurance and meet all guidelines for participation in a clinical experience. Students who work with school nurses must complete a background check. Some counties have additional HIPAA requirements. You must have all forms/proofs completed by School of Nursing deadlines or before the first day of orientation whichever comes first.
I have read and understand the conditions of my participation in the N474 clinical practicum. *
No, please request clarification by e-mailing Professor Becky Damazo at firstname.lastname@example.org
All updates will be sent you via e-mail. Please be sure the e-mail address you list is current and that you check your e-mail at least two weeks prior to the start of the semester.
* = Input is required
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