Undergraduate Clinical Placement Form

Type of Request*

Date*

College/University*

Clinical Coordinator*

Clinical Coordinator Email*

Clinical Coordinator Phone Number *

Unit*

Student Status*

Other

Select up to two days a week: * Monday Tuesday Wednesday Thursday Friday Saturday

Number of Student Groups for this clinical placement*

Start Time*

End Time*

Group 1 Start Date*

Group 1 End Date*

Group 2 Start Date

Group 2 End Date

Group 3 Start Date

Group 3 End Date

Unit*

Date*

Time*

Faculty Name*

Faculty Office Phone Number *

Is the faculty member new to Hackensack University Medical Center?*

Faculty Cell Phone Number *

Comments?