16401 NW 37th Avenue

Miami Gardens, FL 33054

Phone: 305.628.6503

Email: dteran@stu.edu

CLINICAL SITE VISIT INFORMATION SHEET

NUR 420 Community Health Nursing

Student Name: _____________________________________________________________

Phone Numbers: Most Accessible: _______________________________________

Home: _______________________________________________

Work: ________________________________________________

Clinical Site Data

Preceptor Name: _______________________________________________________________

Site Name: ____________________________________________________________________

Site Address: __________________________________________________________________

Site Phone Number: _____________________________________________________________

Please circle what day (s) of the week you will be going to clinical and indicate the time that

you will be at your clinical site

Monday Tuesday Wednesday Thursday Friday Sat/Sunday

Hours: __________________________________________________________________

Are there any days you know you will not be on the clinical site when anticipated?

(i.e. Preceptor away/Spring Break/Conference): ______________________________________

What is the best way to get to your clinical site? Please use true landmarks and posted street

names/numbers. (Maps would be helpful or use next sheet) ______________________________

______________________________________________________________________________

Are there any special instructions to locate you or gain access to site? (Be specific) ___________

______________________________________________________________________________

This form MUST be completed and returned to the Program Director or designee during the

semester prior to registration for the clinical or practicum. The clinical or practicum CANNOT

begin until the Preceptor Information Form and the signed preceptor agreement have been

received by the Nursing Program.

STU Nursing Program NUR 420 Clinical Site Visit Information Sheet. Copyright © 2018