app.smartsheet.com
Open in
urlscan Pro
54.82.157.173
Public Scan
URL:
https://app.smartsheet.com/b/form/d6ef33a82a0e46bc97fd6c835ca91565
Submission: On June 30 via manual from US — Scanned from DE
Submission: On June 30 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
<form>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Student Full Name" data-client-type="text" id="vXL7d6Lm" class="css-1e3khfm ef83ajd0"><label for="text_box_Student Full Name" data-client-id="label_Student Full Name" class="css-1xl1v40 ekxsfat0">Student Full
Name<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Student Full Name" data-client-id="text_box_Student Full Name" data-client-type="" name="vXL7d6Lm" maxlength="4000" class="css-1p0590h e1407lhe0"
value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Student Date of Birth" data-client-type="date" id="nqGRbOGz" class="css-gbq6lm ef83ajd0"><label for="date_Student Date of Birth" data-client-id="label_Student Date of Birth" class="css-1xl1v40 ekxsfat0">Student Date
of Birth<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<p id="description_Student_Date_of_Birth" class="css-1jo9ly9 e5k3c9p0"></p>
<div class="css-1f92r3b"><input data-client-id="date_Student Date of Birth" id="date_Student Date of Birth" aria-label="Student Date of Birth" tabindex="0" name="Student Date of Birth" maxlength="100" class="css-1dpiipj epidubd0"
value=""><button tabindex="0" type="button" aria-label="Choose" class="css-17q24xo"><span title="Choose a date" class="css-14atay6 e1yrjtds0"><svg xmlns="http://www.w3.org/2000/svg" role="img" width="16" height="16" viewBox="0 0 16 16">
<title>Calendar Icon</title>
<desc>Calendar</desc>
<g fill="none" fill-rule="evenodd">
<rect width="13" height="13" x="2" y="2" fill="#005EE0" rx="1"></rect>
<path fill="#FFF"
d="M11.648 12h-.96V8.38c-.351.328-.765.571-1.241.728v-.871c.25-.082.523-.238.817-.467.294-.229.495-.496.605-.801h.779V12zm-6.385-1.33l.93-.112c.03.237.11.418.24.543.129.125.286.188.47.188a.648.648 0 0 0 .502-.226c.135-.15.203-.353.203-.608 0-.241-.065-.433-.195-.574a.621.621 0 0 0-.475-.212c-.123 0-.27.024-.44.072l.105-.783c.26.007.458-.05.595-.17a.602.602 0 0 0 .205-.476.545.545 0 0 0-.15-.403.54.54 0 0 0-.4-.15.579.579 0 0 0-.42.17c-.117.114-.188.28-.213.5l-.885-.151c.061-.303.154-.545.279-.726.124-.182.297-.324.52-.428.221-.103.47-.155.746-.155.472 0 .85.15 1.135.45.234.247.352.525.352.835 0 .44-.24.79-.721 1.053.287.061.516.199.688.413a1.2 1.2 0 0 1 .258.776c0 .44-.16.815-.482 1.125-.32.31-.72.464-1.2.464-.453 0-.829-.13-1.127-.39a1.538 1.538 0 0 1-.52-1.025zM11 5a1 1 0 1 1 0-2 1 1 0 0 1 0 2zM6 5a1 1 0 1 1 0-2 1 1 0 0 1 0 2z">
</path>
</g>
</svg></span></button></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Student School Email Address" data-client-type="text" id="6JdGvNzG" class="css-1e3khfm ef83ajd0"><label for="text_box_Student School Email Address" data-client-id="label_Student School Email Address"
class="css-1xl1v40 ekxsfat0">Student School Email Address<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Student School Email Address" data-client-id="text_box_Student School Email Address" data-client-type="" name="6JdGvNzG" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div role="application" title="" data-client-id="container_School Name" data-client-type="dropdown" id="mdPqrEbD" class="css-u3yn36 ef83ajd0"><label for="select_input_School Name" id="75e4851f-f078-4ec6-b587-8dbed6b1137f"
data-client-id="label_School Name" class="css-1xl1v40 ekxsfat0">School Name<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div class="css-t8xanh-container">
<div class="css-kf2egt-control react-select__control">
<div class="css-11ksah1 react-select__value-container">
<div class="css-1i5h0xy-placeholder react-select__placeholder">Select</div>
<div class="css-1g6gooi">
<div class="react-select__input" style="display: inline-block;"><input autocapitalize="none" autocomplete="off" autocorrect="off" id="select_input_School Name" spellcheck="false" tabindex="0" type="text" aria-label="Select"
aria-labelledby="75e4851f-f078-4ec6-b587-8dbed6b1137f" value="" style="box-sizing: content-box; width: 2px; background: 0px center; border: 0px; font-size: inherit; opacity: 1; outline: 0px; padding: 0px; color: inherit;">
<div
style="position: absolute; top: 0px; left: 0px; visibility: hidden; height: 0px; overflow: scroll; white-space: pre; font-size: 13px; font-family: Arial; font-weight: 400; font-style: normal; letter-spacing: normal; text-transform: none;">
</div>
</div>
</div>
</div>
<div class="css-1wy0on6 react-select__indicators"><span class="css-9lpq22-indicatorSeparator react-select__indicator-separator"></span><span style="margin-right: 6px;"><svg data-client-id="caret_icon" width="16px" height="16px"
viewBox="0 0 16 16" version="1.1" role="img" xmlns="http://www.w3.org/2000/svg">
<title>Caret Icon</title>
<desc>Caret symbol</desc>
<g stroke="none" stroke-width="1" fill="none" fill-rule="evenodd">
<g fill="#161616">
<path
d="M8.38951287,9.81740951 C8.3743818,9.83527284 8.35811596,9.85207547 8.34082332,9.86770589 C8.12569934,10.0621513 7.79871352,10.0396329 7.61048004,9.81740951 L5.12806062,6.88673235 C5.04550447,6.78926879 5,6.66416424 5,6.53465776 C5,6.23937443 5.23172713,6 5.51757703,6 L10.4824159,6 C10.607785,6 10.7288928,6.04700617 10.8232427,6.13228679 C11.0383667,6.32673222 11.0601658,6.664509 10.8719323,6.88673235 L8.38951287,9.81740951 Z">
</path>
</g>
</g>
</svg></span></div>
</div>
</div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_If you selected other, list school name here" data-client-type="text" id="YkXEWm8O" class="css-1e3khfm ef83ajd0"><label for="text_box_If you selected other, list school name here"
data-client-id="label_If you selected other, list school name here" class="css-1xl1v40 ekxsfat0">If you selected other, list school name here<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div id="description_If_you_selected_other__list_school_name_here" class="rich-text-field-desc">
<p>Please note, if your school name is not listed above,</p>
<p>VUMC does not have a current affiliation agreement</p>
<p>with your institution and 6-8 weeks will be required</p>
<p>to establish this agreement.</p>
</div>
<div style="display: flex;"><input title="" aria-invalid="false" aria-describedby="description_If_you_selected_other__list_school_name_here" tabindex="-1" id="text_box_If you selected other, list school name here"
data-client-id="text_box_If you selected other, list school name here" data-client-type="" name="YkXEWm8O" maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_School Contact Information" data-client-type="text" id="R51egZWz" class="css-1e3khfm ef83ajd0"><label for="text_box_School Contact Information" data-client-id="label_School Contact Information"
class="css-1xl1v40 ekxsfat0">School Contact Information<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div id="description_School_Contact_Information" class="rich-text-field-desc">
<p>Contact to establish an Affiliation Agreement.</p>
</div>
<div style="display: flex;"><input title="" aria-invalid="false" aria-describedby="description_School_Contact_Information" tabindex="-1" id="text_box_School Contact Information" data-client-id="text_box_School Contact Information"
data-client-type="EMAIL" name="R51egZWz" maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Program Description" data-client-type="divider" class="css-1e2fy0l e14sboee0">
<hr data-client-id="Program Description" class="css-1xs1ymt e14sboee2">
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div role="application" title="" data-client-id="container_Are you an NP, PA or Midwifery Student?" data-client-type="dropdown" id="omkJJPnG" class="css-u3yn36 ef83ajd0"><label for="select_input_Are you an NP, PA or Midwifery Student?"
id="d5aa7f85-8ba5-4a36-9d71-c0d46e75d63a" data-client-id="label_Are you an NP, PA or Midwifery Student?" class="css-1xl1v40 ekxsfat0">Are you an NP, PA or Midwifery Student?<span data-client-id="required_indicator"
class="css-skcghl ekxsfat1">*</span></label>
<div class="css-t8xanh-container">
<div class="css-kf2egt-control react-select__control">
<div class="css-11ksah1 react-select__value-container">
<div class="css-1i5h0xy-placeholder react-select__placeholder">Select or enter value</div>
<div class="css-1g6gooi">
<div class="react-select__input" style="display: inline-block;"><input autocapitalize="none" autocomplete="off" autocorrect="off" id="select_input_Are you an NP, PA or Midwifery Student?" spellcheck="false" tabindex="0" type="text"
aria-label="Select or enter value" aria-labelledby="d5aa7f85-8ba5-4a36-9d71-c0d46e75d63a" value=""
style="box-sizing: content-box; width: 2px; background: 0px center; border: 0px; font-size: inherit; opacity: 1; outline: 0px; padding: 0px; color: inherit;">
<div
style="position: absolute; top: 0px; left: 0px; visibility: hidden; height: 0px; overflow: scroll; white-space: pre; font-size: 13px; font-family: Arial; font-weight: 400; font-style: normal; letter-spacing: normal; text-transform: none;">
</div>
</div>
</div>
</div>
<div class="css-1wy0on6 react-select__indicators"><span class="css-9lpq22-indicatorSeparator react-select__indicator-separator"></span><span style="margin-right: 6px;"><svg data-client-id="caret_icon" width="16px" height="16px"
viewBox="0 0 16 16" version="1.1" role="img" xmlns="http://www.w3.org/2000/svg">
<title>Caret Icon</title>
<desc>Caret symbol</desc>
<g stroke="none" stroke-width="1" fill="none" fill-rule="evenodd">
<g fill="#161616">
<path
d="M8.38951287,9.81740951 C8.3743818,9.83527284 8.35811596,9.85207547 8.34082332,9.86770589 C8.12569934,10.0621513 7.79871352,10.0396329 7.61048004,9.81740951 L5.12806062,6.88673235 C5.04550447,6.78926879 5,6.66416424 5,6.53465776 C5,6.23937443 5.23172713,6 5.51757703,6 L10.4824159,6 C10.607785,6 10.7288928,6.04700617 10.8232427,6.13228679 C11.0383667,6.32673222 11.0601658,6.664509 10.8719323,6.88673235 L8.38951287,9.81740951 Z">
</path>
</g>
</g>
</svg></span></div>
</div>
</div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div role="application" title="" data-client-id="container_Type of Program for Advanced Practice Student" data-client-type="dropdown" id="NvMy9vDn" class="css-u3yn36 ef83ajd0"><label
for="select_input_Type of Program for Advanced Practice Student" id="cf724759-301c-4571-aa94-f5110ae84175" data-client-id="label_Type of Program for Advanced Practice Student" class="css-1xl1v40 ekxsfat0">Type of Program for Advanced Practice
Student<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div class="css-t8xanh-container">
<div class="css-kf2egt-control react-select__control">
<div class="css-11ksah1 react-select__value-container">
<div class="css-1i5h0xy-placeholder react-select__placeholder">Select or enter value</div>
<div class="css-1g6gooi">
<div class="react-select__input" style="display: inline-block;"><input autocapitalize="none" autocomplete="off" autocorrect="off" id="select_input_Type of Program for Advanced Practice Student" spellcheck="false" tabindex="-1"
type="text" aria-label="Select or enter value" aria-labelledby="cf724759-301c-4571-aa94-f5110ae84175" value=""
style="box-sizing: content-box; width: 2px; background: 0px center; border: 0px; font-size: inherit; opacity: 1; outline: 0px; padding: 0px; color: inherit;">
<div
style="position: absolute; top: 0px; left: 0px; visibility: hidden; height: 0px; overflow: scroll; white-space: pre; font-size: 13px; font-family: Arial; font-weight: 400; font-style: normal; letter-spacing: normal; text-transform: none;">
</div>
</div>
</div>
</div>
<div class="css-1wy0on6 react-select__indicators"><span class="css-9lpq22-indicatorSeparator react-select__indicator-separator"></span><span style="margin-right: 6px;"><svg data-client-id="caret_icon" width="16px" height="16px"
viewBox="0 0 16 16" version="1.1" role="img" xmlns="http://www.w3.org/2000/svg">
<title>Caret Icon</title>
<desc>Caret symbol</desc>
<g stroke="none" stroke-width="1" fill="none" fill-rule="evenodd">
<g fill="#161616">
<path
d="M8.38951287,9.81740951 C8.3743818,9.83527284 8.35811596,9.85207547 8.34082332,9.86770589 C8.12569934,10.0621513 7.79871352,10.0396329 7.61048004,9.81740951 L5.12806062,6.88673235 C5.04550447,6.78926879 5,6.66416424 5,6.53465776 C5,6.23937443 5.23172713,6 5.51757703,6 L10.4824159,6 C10.607785,6 10.7288928,6.04700617 10.8232427,6.13228679 C11.0383667,6.32673222 11.0601658,6.664509 10.8719323,6.88673235 L8.38951287,9.81740951 Z">
</path>
</g>
</g>
</svg></span></div>
</div>
</div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div role="application" title="" data-client-id="container_Program Specialty" data-client-type="dropdown" id="kekJgwP9" class="css-u3yn36 ef83ajd0"><label for="select_input_Program Specialty" id="084ad244-a165-4778-b43a-464ad9234888"
data-client-id="label_Program Specialty" class="css-1xl1v40 ekxsfat0">Program Specialty<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div class="css-t8xanh-container">
<div class="css-kf2egt-control react-select__control">
<div class="css-11ksah1 react-select__value-container">
<div class="css-1i5h0xy-placeholder react-select__placeholder">Select or enter value</div>
<div class="css-1g6gooi">
<div class="react-select__input" style="display: inline-block;"><input autocapitalize="none" autocomplete="off" autocorrect="off" id="select_input_Program Specialty" spellcheck="false" tabindex="-1" type="text"
aria-label="Select or enter value" aria-labelledby="084ad244-a165-4778-b43a-464ad9234888" value=""
style="box-sizing: content-box; width: 2px; background: 0px center; border: 0px; font-size: inherit; opacity: 1; outline: 0px; padding: 0px; color: inherit;">
<div
style="position: absolute; top: 0px; left: 0px; visibility: hidden; height: 0px; overflow: scroll; white-space: pre; font-size: 13px; font-family: Arial; font-weight: 400; font-style: normal; letter-spacing: normal; text-transform: none;">
</div>
</div>
</div>
</div>
<div class="css-1wy0on6 react-select__indicators"><span class="css-9lpq22-indicatorSeparator react-select__indicator-separator"></span><span style="margin-right: 6px;"><svg data-client-id="caret_icon" width="16px" height="16px"
viewBox="0 0 16 16" version="1.1" role="img" xmlns="http://www.w3.org/2000/svg">
<title>Caret Icon</title>
<desc>Caret symbol</desc>
<g stroke="none" stroke-width="1" fill="none" fill-rule="evenodd">
<g fill="#161616">
<path
d="M8.38951287,9.81740951 C8.3743818,9.83527284 8.35811596,9.85207547 8.34082332,9.86770589 C8.12569934,10.0621513 7.79871352,10.0396329 7.61048004,9.81740951 L5.12806062,6.88673235 C5.04550447,6.78926879 5,6.66416424 5,6.53465776 C5,6.23937443 5.23172713,6 5.51757703,6 L10.4824159,6 C10.607785,6 10.7288928,6.04700617 10.8232427,6.13228679 C11.0383667,6.32673222 11.0601658,6.664509 10.8719323,6.88673235 L8.38951287,9.81740951 Z">
</path>
</g>
</g>
</svg></span></div>
</div>
</div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_Program Spcialty: Other" data-client-type="text" id="0qLo21Om" class="css-1e3khfm ef83ajd0"><label for="textarea_Program Spcialty: Other" data-client-id="label_Program Spcialty: Other"
class="css-1xl1v40 ekxsfat0">Program Spcialty: Other<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label><textarea aria-invalid="false" tabindex="-1" name="0qLo21Om" id="textarea_Program Spcialty: Other"
data-client-id="textarea_Program Spcialty: Other" maxlength="4000" rows="3" class="css-1lh64kx e1407lhe1"></textarea></div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div role="application" title="" data-client-id="container_Program of Study" data-client-type="dropdown" id="EmQM23Jl" class="css-u3yn36 ef83ajd0"><label for="select_input_Program of Study" id="b03ee37e-e809-4012-8f4a-dcf8a7178c36"
data-client-id="label_Program of Study" class="css-1xl1v40 ekxsfat0">Program of Study<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div class="css-t8xanh-container">
<div class="css-kf2egt-control react-select__control">
<div class="css-11ksah1 react-select__value-container">
<div class="css-1i5h0xy-placeholder react-select__placeholder">Select</div>
<div class="css-1g6gooi">
<div class="react-select__input" style="display: inline-block;"><input autocapitalize="none" autocomplete="off" autocorrect="off" id="select_input_Program of Study" spellcheck="false" tabindex="-1" type="text" aria-label="Select"
aria-labelledby="b03ee37e-e809-4012-8f4a-dcf8a7178c36" value="" style="box-sizing: content-box; width: 2px; background: 0px center; border: 0px; font-size: inherit; opacity: 1; outline: 0px; padding: 0px; color: inherit;">
<div
style="position: absolute; top: 0px; left: 0px; visibility: hidden; height: 0px; overflow: scroll; white-space: pre; font-size: 13px; font-family: Arial; font-weight: 400; font-style: normal; letter-spacing: normal; text-transform: none;">
</div>
</div>
</div>
</div>
<div class="css-1wy0on6 react-select__indicators"><span class="css-9lpq22-indicatorSeparator react-select__indicator-separator"></span><span style="margin-right: 6px;"><svg data-client-id="caret_icon" width="16px" height="16px"
viewBox="0 0 16 16" version="1.1" role="img" xmlns="http://www.w3.org/2000/svg">
<title>Caret Icon</title>
<desc>Caret symbol</desc>
<g stroke="none" stroke-width="1" fill="none" fill-rule="evenodd">
<g fill="#161616">
<path
d="M8.38951287,9.81740951 C8.3743818,9.83527284 8.35811596,9.85207547 8.34082332,9.86770589 C8.12569934,10.0621513 7.79871352,10.0396329 7.61048004,9.81740951 L5.12806062,6.88673235 C5.04550447,6.78926879 5,6.66416424 5,6.53465776 C5,6.23937443 5.23172713,6 5.51757703,6 L10.4824159,6 C10.607785,6 10.7288928,6.04700617 10.8232427,6.13228679 C11.0383667,6.32673222 11.0601658,6.664509 10.8719323,6.88673235 L8.38951287,9.81740951 Z">
</path>
</g>
</g>
</svg></span></div>
</div>
</div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div role="application" title="" data-client-id="container_Type of Program" data-client-type="dropdown" id="XmYAZZDd" class="css-u3yn36 ef83ajd0"><label for="select_input_Type of Program" id="1437897d-a62f-4498-b680-43e6b9df2725"
data-client-id="label_Type of Program" class="css-1xl1v40 ekxsfat0">Type of Program<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div class="css-t8xanh-container">
<div class="css-kf2egt-control react-select__control">
<div class="css-11ksah1 react-select__value-container">
<div class="css-1i5h0xy-placeholder react-select__placeholder">Select or enter value</div>
<div class="css-1g6gooi">
<div class="react-select__input" style="display: inline-block;"><input autocapitalize="none" autocomplete="off" autocorrect="off" id="select_input_Type of Program" spellcheck="false" tabindex="-1" type="text"
aria-label="Select or enter value" aria-labelledby="1437897d-a62f-4498-b680-43e6b9df2725" value=""
style="box-sizing: content-box; width: 2px; background: 0px center; border: 0px; font-size: inherit; opacity: 1; outline: 0px; padding: 0px; color: inherit;">
<div
style="position: absolute; top: 0px; left: 0px; visibility: hidden; height: 0px; overflow: scroll; white-space: pre; font-size: 13px; font-family: Arial; font-weight: 400; font-style: normal; letter-spacing: normal; text-transform: none;">
</div>
</div>
</div>
</div>
<div class="css-1wy0on6 react-select__indicators"><span class="css-9lpq22-indicatorSeparator react-select__indicator-separator"></span><span style="margin-right: 6px;"><svg data-client-id="caret_icon" width="16px" height="16px"
viewBox="0 0 16 16" version="1.1" role="img" xmlns="http://www.w3.org/2000/svg">
<title>Caret Icon</title>
<desc>Caret symbol</desc>
<g stroke="none" stroke-width="1" fill="none" fill-rule="evenodd">
<g fill="#161616">
<path
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</svg></span></div>
</div>
</div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_Program of Study: Other" data-client-type="text" id="yMj86kOa" class="css-1e3khfm ef83ajd0"><label for="textarea_Program of Study: Other" data-client-id="label_Program of Study: Other"
class="css-1xl1v40 ekxsfat0">Program of Study: Other<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label><textarea aria-invalid="false" tabindex="-1" name="yMj86kOa" id="textarea_Program of Study: Other"
data-client-id="textarea_Program of Study: Other" maxlength="4000" rows="3" class="css-1lh64kx e1407lhe1"></textarea></div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_Confirmed Preceptor Full Name" data-client-type="text" id="Z5LawrQpn" class="css-1e3khfm ef83ajd0"><label for="textarea_Confirmed Preceptor Full Name" data-client-id="label_Confirmed Preceptor Full Name"
class="css-1xl1v40 ekxsfat0">Confirmed Preceptor Full Name<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div id="description_Confirmed_Preceptor_Full_Name" class="rich-text-field-desc">
<p>Please list:</p>
<p>Name of Preceptor</p>
<p>Preceptor Work Area</p>
<p><br></p>
<p><strong style="color: rgb(161, 0, 0);">If you have NOT identified a preceptor:</strong></p>
<p>Please know that the availability of preceptors is limited and based on your request and verification of preceptor willingness and availability.</p>
<p><br></p>
<p><strong style="color: rgb(161, 0, 0);">Please DO NOT submit this survey.</strong></p>
<p>If you have any further questions, please do not hesitate to contact us at student.placement@vumc.org.</p>
</div><textarea aria-invalid="false" aria-describedby="description_Confirmed_Preceptor_Full_Name" tabindex="-1" name="Z5LawrQpn" id="textarea_Confirmed Preceptor Full Name" data-client-id="textarea_Confirmed Preceptor Full Name"
maxlength="4000" rows="3" class="css-1lh64kx e1407lhe1"></textarea>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div role="application" title="" data-client-id="container_Confirmed Preceptor Credentials" data-client-type="dropdown" id="D0vW1Mweo" class="css-u3yn36 ef83ajd0"><label for="select_input_Confirmed Preceptor Credentials"
id="9babd0be-2595-4057-a102-be7b55ff3a48" data-client-id="label_Confirmed Preceptor Credentials" class="css-1xl1v40 ekxsfat0">Confirmed Preceptor Credentials</label>
<div class="css-t8xanh-container">
<div class="css-kf2egt-control react-select__control">
<div class="css-11ksah1 react-select__value-container">
<div class="css-1i5h0xy-placeholder react-select__placeholder">Select or enter value</div>
<div class="css-1g6gooi">
<div class="react-select__input" style="display: inline-block;"><input autocapitalize="none" autocomplete="off" autocorrect="off" id="select_input_Confirmed Preceptor Credentials" spellcheck="false" tabindex="-1" type="text"
aria-label="Select or enter value" aria-labelledby="9babd0be-2595-4057-a102-be7b55ff3a48" value=""
style="box-sizing: content-box; width: 2px; background: 0px center; border: 0px; font-size: inherit; opacity: 1; outline: 0px; padding: 0px; color: inherit;">
<div
style="position: absolute; top: 0px; left: 0px; visibility: hidden; height: 0px; overflow: scroll; white-space: pre; font-size: 13px; font-family: Arial; font-weight: 400; font-style: normal; letter-spacing: normal; text-transform: none;">
</div>
</div>
</div>
</div>
<div class="css-1wy0on6 react-select__indicators"><span class="css-9lpq22-indicatorSeparator react-select__indicator-separator"></span><span style="margin-right: 6px;"><svg data-client-id="caret_icon" width="16px" height="16px"
viewBox="0 0 16 16" version="1.1" role="img" xmlns="http://www.w3.org/2000/svg">
<title>Caret Icon</title>
<desc>Caret symbol</desc>
<g stroke="none" stroke-width="1" fill="none" fill-rule="evenodd">
<g fill="#161616">
<path
d="M8.38951287,9.81740951 C8.3743818,9.83527284 8.35811596,9.85207547 8.34082332,9.86770589 C8.12569934,10.0621513 7.79871352,10.0396329 7.61048004,9.81740951 L5.12806062,6.88673235 C5.04550447,6.78926879 5,6.66416424 5,6.53465776 C5,6.23937443 5.23172713,6 5.51757703,6 L10.4824159,6 C10.607785,6 10.7288928,6.04700617 10.8232427,6.13228679 C11.0383667,6.32673222 11.0601658,6.664509 10.8719323,6.88673235 L8.38951287,9.81740951 Z">
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</svg></span></div>
</div>
</div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_Confirmed Preceptor Contact Information." data-client-type="text" id="AJbdRzaw" class="css-1e3khfm ef83ajd0"><label for="text_box_Confirmed Preceptor Contact Information."
data-client-id="label_Confirmed Preceptor Contact Information." class="css-1xl1v40 ekxsfat0">Confirmed Preceptor Contact Information.<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div id="description_Confirmed_Preceptor_Contact_Information_" class="rich-text-field-desc">
<p>Please list your preceptor's VUMC Email Address</p>
</div>
<div style="display: flex;"><input title="" aria-invalid="false" aria-describedby="description_Confirmed_Preceptor_Contact_Information_" tabindex="-1" id="text_box_Confirmed Preceptor Contact Information."
data-client-id="text_box_Confirmed Preceptor Contact Information." data-client-type="" name="AJbdRzaw" maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<fieldset data-client-id="container_Do you have a preferred preceptor?" data-client-type="radio" data-client-align="vertical" id="PmlwgZzQ" class="css-110bzo0 etth7i50">
<legend data-client-id="label_Do you have a preferred preceptor?" class="css-1yfbzum etth7i52">Do you have a preferred preceptor?<span data-client-id="required_indicator" class="css-mfmuai etth7i53">*</span></legend>
<div class="css-ml5vzx etth7i51">
<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="Yes" tabindex="-1" data-client-value="Yes" data-client-id="radio_Do you have a preferred preceptor?" type="radio" title="Yes" name="PmlwgZzQ"
class="css-10i6ipn etth7i57"><span class="css-1pu7ejh etth7i58">Yes</span></label></div>
<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="No" tabindex="-1" data-client-value="No" data-client-id="radio_Do you have a preferred preceptor?" type="radio" title="No" name="PmlwgZzQ"
class="css-10i6ipn etth7i57"><span class="css-1pu7ejh etth7i58">No</span></label></div>
</div>
</fieldset>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_Preferred Preceptor Full Name" data-client-type="text" id="2g0dmDOd" class="css-1e3khfm ef83ajd0"><label for="textarea_Preferred Preceptor Full Name" data-client-id="label_Preferred Preceptor Full Name"
class="css-1xl1v40 ekxsfat0">Preferred Preceptor Full Name<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div id="description_Preferred_Preceptor_Full_Name" class="rich-text-field-desc">
<p><strong><em>Include preceptor information pertinent to the clinical area of interest. A new form must be submitted for each clinical area of interest.</em></strong></p>
<p><br></p>
<p>Please list:</p>
<p>Name of Preceptor</p>
<p>Preceptor Work Area</p>
</div><textarea aria-invalid="false" aria-describedby="description_Preferred_Preceptor_Full_Name" tabindex="-1" name="2g0dmDOd" id="textarea_Preferred Preceptor Full Name" data-client-id="textarea_Preferred Preceptor Full Name" maxlength="4000"
rows="3" class="css-1lh64kx e1407lhe1"></textarea>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div role="application" title="" data-client-id="container_Preferred Preceptors Credentials" data-client-type="dropdown" id="ROp7AkKw5" class="css-u3yn36 ef83ajd0"><label for="select_input_Preferred Preceptors Credentials"
id="6e196ca5-3e66-44d2-885d-c0088d10895e" data-client-id="label_Preferred Preceptors Credentials" class="css-1xl1v40 ekxsfat0">Preferred Preceptors Credentials<span data-client-id="required_indicator"
class="css-skcghl ekxsfat1">*</span></label>
<div class="css-t8xanh-container">
<div class="css-kf2egt-control react-select__control">
<div class="css-11ksah1 react-select__value-container react-select__value-container--is-multi">
<div class="css-1i5h0xy-placeholder react-select__placeholder">Select or enter value</div>
<div class="css-1g6gooi">
<div class="react-select__input" style="display: inline-block;"><input autocapitalize="none" autocomplete="off" autocorrect="off" id="select_input_Preferred Preceptors Credentials" spellcheck="false" tabindex="-1" type="text"
aria-label="Select or enter value" aria-labelledby="6e196ca5-3e66-44d2-885d-c0088d10895e" value=""
style="box-sizing: content-box; width: 2px; background: 0px center; border: 0px; font-size: inherit; opacity: 1; outline: 0px; padding: 0px; color: inherit;">
<div
style="position: absolute; top: 0px; left: 0px; visibility: hidden; height: 0px; overflow: scroll; white-space: pre; font-size: 13px; font-family: Arial; font-weight: 400; font-style: normal; letter-spacing: normal; text-transform: none;">
</div>
</div>
</div>
</div>
<div class="css-1wy0on6 react-select__indicators"><span class="css-9lpq22-indicatorSeparator react-select__indicator-separator"></span><span style="margin-right: 6px;"><svg data-client-id="caret_icon" width="16px" height="16px"
viewBox="0 0 16 16" version="1.1" role="img" xmlns="http://www.w3.org/2000/svg">
<title>Caret Icon</title>
<desc>Caret symbol</desc>
<g stroke="none" stroke-width="1" fill="none" fill-rule="evenodd">
<g fill="#161616">
<path
d="M8.38951287,9.81740951 C8.3743818,9.83527284 8.35811596,9.85207547 8.34082332,9.86770589 C8.12569934,10.0621513 7.79871352,10.0396329 7.61048004,9.81740951 L5.12806062,6.88673235 C5.04550447,6.78926879 5,6.66416424 5,6.53465776 C5,6.23937443 5.23172713,6 5.51757703,6 L10.4824159,6 C10.607785,6 10.7288928,6.04700617 10.8232427,6.13228679 C11.0383667,6.32673222 11.0601658,6.664509 10.8719323,6.88673235 L8.38951287,9.81740951 Z">
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</g>
</svg></span></div>
</div>
</div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_Other: " data-client-type="text" id="6wzKvPZ37" class="css-1e3khfm ef83ajd0"><label for="textarea_Other: " data-client-id="label_Other: " class="css-1xl1v40 ekxsfat0">Other: </label><textarea aria-invalid="false"
tabindex="-1" name="6wzKvPZ37" id="textarea_Other: " data-client-id="textarea_Other: " maxlength="4000" rows="3" class="css-1lh64kx e1407lhe1"></textarea></div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_Preferred Preceptor VUMC Email" data-client-type="text" id="Ykd3Xq9W" class="css-1e3khfm ef83ajd0"><label for="text_box_Preferred Preceptor VUMC Email" data-client-id="label_Preferred Preceptor VUMC Email"
class="css-1xl1v40 ekxsfat0">Preferred Preceptor VUMC Email<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="-1" id="text_box_Preferred Preceptor VUMC Email" data-client-id="text_box_Preferred Preceptor VUMC Email" data-client-type="" name="Ykd3Xq9W" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<fieldset data-client-id="container_Do you have a 2nd preferred preceptor?" data-client-type="radio" data-client-align="vertical" id="oyknoy66g" class="css-110bzo0 etth7i50">
<legend data-client-id="label_Do you have a 2nd preferred preceptor?" class="css-1yfbzum etth7i52">Do you have a 2nd preferred preceptor?<span data-client-id="required_indicator" class="css-mfmuai etth7i53">*</span></legend>
<div class="css-ml5vzx etth7i51">
<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="Yes" tabindex="-1" data-client-value="Yes" data-client-id="radio_Do you have a 2nd preferred preceptor?" type="radio" title="Yes" name="oyknoy66g"
class="css-10i6ipn etth7i57"><span class="css-1pu7ejh etth7i58">Yes</span></label></div>
<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="No" tabindex="-1" data-client-value="No" data-client-id="radio_Do you have a 2nd preferred preceptor?" type="radio" title="No" name="oyknoy66g"
class="css-10i6ipn etth7i57"><span class="css-1pu7ejh etth7i58">No</span></label></div>
</div>
</fieldset>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_2nd Preferred Preceptors Full Name" data-client-type="text" id="31zAZLyoW" class="css-1e3khfm ef83ajd0"><label for="text_box_2nd Preferred Preceptors Full Name"
data-client-id="label_2nd Preferred Preceptors Full Name" class="css-1xl1v40 ekxsfat0">2nd Preferred Preceptors Full Name<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div id="description_2nd_Preferred_Preceptors_Full_Name" class="rich-text-field-desc">
<p>Please list:</p>
<p>Name of Preceptor</p>
<p>Preceptor Work Area</p>
</div>
<div style="display: flex;"><input title="" aria-invalid="false" aria-describedby="description_2nd_Preferred_Preceptors_Full_Name" tabindex="-1" id="text_box_2nd Preferred Preceptors Full Name"
data-client-id="text_box_2nd Preferred Preceptors Full Name" data-client-type="" name="31zAZLyoW" maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div role="application" title="" data-client-id="container_2nd Preferred Preceptors Credentials" data-client-type="dropdown" id="1zW9ZAmjk" class="css-u3yn36 ef83ajd0"><label for="select_input_2nd Preferred Preceptors Credentials"
id="41825544-2ef8-4137-979f-121c5e27bfa3" data-client-id="label_2nd Preferred Preceptors Credentials" class="css-1xl1v40 ekxsfat0">2nd Preferred Preceptors Credentials<span data-client-id="required_indicator"
class="css-skcghl ekxsfat1">*</span></label>
<div class="css-t8xanh-container">
<div class="css-kf2egt-control react-select__control">
<div class="css-11ksah1 react-select__value-container">
<div class="css-1i5h0xy-placeholder react-select__placeholder">Select or enter value</div>
<div class="css-1g6gooi">
<div class="react-select__input" style="display: inline-block;"><input autocapitalize="none" autocomplete="off" autocorrect="off" id="select_input_2nd Preferred Preceptors Credentials" spellcheck="false" tabindex="-1" type="text"
aria-label="Select or enter value" aria-labelledby="41825544-2ef8-4137-979f-121c5e27bfa3" value=""
style="box-sizing: content-box; width: 2px; background: 0px center; border: 0px; font-size: inherit; opacity: 1; outline: 0px; padding: 0px; color: inherit;">
<div
style="position: absolute; top: 0px; left: 0px; visibility: hidden; height: 0px; overflow: scroll; white-space: pre; font-size: 13px; font-family: Arial; font-weight: 400; font-style: normal; letter-spacing: normal; text-transform: none;">
</div>
</div>
</div>
</div>
<div class="css-1wy0on6 react-select__indicators"><span class="css-9lpq22-indicatorSeparator react-select__indicator-separator"></span><span style="margin-right: 6px;"><svg data-client-id="caret_icon" width="16px" height="16px"
viewBox="0 0 16 16" version="1.1" role="img" xmlns="http://www.w3.org/2000/svg">
<title>Caret Icon</title>
<desc>Caret symbol</desc>
<g stroke="none" stroke-width="1" fill="none" fill-rule="evenodd">
<g fill="#161616">
<path
d="M8.38951287,9.81740951 C8.3743818,9.83527284 8.35811596,9.85207547 8.34082332,9.86770589 C8.12569934,10.0621513 7.79871352,10.0396329 7.61048004,9.81740951 L5.12806062,6.88673235 C5.04550447,6.78926879 5,6.66416424 5,6.53465776 C5,6.23937443 5.23172713,6 5.51757703,6 L10.4824159,6 C10.607785,6 10.7288928,6.04700617 10.8232427,6.13228679 C11.0383667,6.32673222 11.0601658,6.664509 10.8719323,6.88673235 L8.38951287,9.81740951 Z">
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</svg></span></div>
</div>
</div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_2nd Preferred Preceptor Other" data-client-type="text" id="M8pr8v1lr" class="css-1e3khfm ef83ajd0"><label for="textarea_2nd Preferred Preceptor Other" data-client-id="label_2nd Preferred Preceptor Other"
class="css-1xl1v40 ekxsfat0">2nd Preferred Preceptor Other</label><textarea aria-invalid="false" tabindex="-1" name="M8pr8v1lr" id="textarea_2nd Preferred Preceptor Other" data-client-id="textarea_2nd Preferred Preceptor Other"
maxlength="4000" rows="3" class="css-1lh64kx e1407lhe1"></textarea></div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_2nd Preferred Preceptors VUMC Email" data-client-type="text" id="jXkwWy2rL" class="css-1e3khfm ef83ajd0"><label for="text_box_2nd Preferred Preceptors VUMC Email"
data-client-id="label_2nd Preferred Preceptors VUMC Email" class="css-1xl1v40 ekxsfat0">2nd Preferred Preceptors VUMC Email<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="-1" id="text_box_2nd Preferred Preceptors VUMC Email" data-client-id="text_box_2nd Preferred Preceptors VUMC Email" data-client-type="" name="jXkwWy2rL" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<fieldset data-client-id="container_Research or quality improvement project required?" data-client-type="radio" data-client-align="vertical" id="nqGv0L5z" class="css-110bzo0 etth7i50">
<legend data-client-id="label_Research or quality improvement project required?" class="css-1yfbzum etth7i52">Research or quality improvement project required?</legend>
<div class="rich-text-field-desc css-1y2mbba" id="description_Research_or_quality_improvement_project_required_">
<p>Any human subjects research that takes place at VUMC will need to be submitted to the VUMC IRB.</p>
<p>Please review the <a rel="nofollow noreferrer noopener" href="https://acrobat.adobe.com/link/review?uri=urn:aaid:scds:US:70298416-8623-35a8-bcef-8f6d42b98267">Research IRB Instructions</a> for further information.<strong
style="color: rgb(161, 0, 0);"> **Please right click link and open in new window**</strong></p>
</div>
<div class="css-ml5vzx etth7i51">
<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="Yes" aria-describedby="description_Research_or_quality_improvement_project_required_" tabindex="0" data-client-value="Yes"
data-client-id="radio_Research or quality improvement project required?" type="radio" title="Yes" name="nqGv0L5z" class="css-10i6ipn etth7i57"><span class="css-1pu7ejh etth7i58">Yes</span></label></div>
<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="No" aria-describedby="description_Research_or_quality_improvement_project_required_" tabindex="0" data-client-value="No"
data-client-id="radio_Research or quality improvement project required?" type="radio" title="No" name="nqGv0L5z" class="css-10i6ipn etth7i57"><span class="css-1pu7ejh etth7i58">No</span></label></div>
</div>
</fieldset>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Start Date" data-client-type="date" id="EmQk1YZY" class="css-gbq6lm ef83ajd0"><label for="date_Start Date" data-client-id="label_Start Date" class="css-1xl1v40 ekxsfat0">Start Date<span
data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<p id="description_Start_Date" class="css-1jo9ly9 e5k3c9p0"></p>
<div class="css-1f92r3b"><input data-client-id="date_Start Date" id="date_Start Date" aria-label="Start Date" tabindex="0" name="Start Date" maxlength="100" class="css-1dpiipj epidubd0" value=""><button tabindex="0" type="button"
aria-label="Choose" class="css-17q24xo"><span title="Choose a date" class="css-14atay6 e1yrjtds0"><svg xmlns="http://www.w3.org/2000/svg" role="img" width="16" height="16" viewBox="0 0 16 16">
<title>Calendar Icon</title>
<desc>Calendar</desc>
<g fill="none" fill-rule="evenodd">
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<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="Family Medicine" tabindex="-1" data-client-value="Family Medicine" data-client-id="radio_VMG Area of Placement" type="radio" title="Family Medicine"
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<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="Women's Health" tabindex="-1" data-client-value="Women's Health" data-client-id="radio_VMG Area of Placement" type="radio" title="Women's Health"
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<div data-client-id="container_VMG Other (please list)" data-client-type="text" id="MbePnJL7" class="css-1e3khfm ef83ajd0"><label for="textarea_VMG Other (please list)" data-client-id="label_VMG Other (please list)"
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<legend data-client-id="label_VPH Area of Placement" class="css-1yfbzum etth7i52">VPH Area of Placement<span data-client-id="required_indicator" class="css-mfmuai etth7i53">*</span></legend>
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<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="Inpatient" tabindex="-1" data-client-value="Inpatient" data-client-id="radio_VPH Area of Placement" type="radio" title="Inpatient" name="JzDQ9X9M"
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<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="Outpatient" tabindex="-1" data-client-value="Outpatient" data-client-id="radio_VPH Area of Placement" type="radio" title="Outpatient" name="JzDQ9X9M"
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<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_VWCH Other (please list)" data-client-type="text" id="qa03e5Ye" class="css-1e3khfm ef83ajd0"><label for="textarea_VWCH Other (please list)" data-client-id="label_VWCH Other (please list)"
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<fieldset data-client-id="container_VBCH Area of Placement" data-client-type="radio" data-client-align="vertical" id="mdP7XaKD" class="css-110bzo0 etth7i50">
<legend data-client-id="label_VBCH Area of Placement" class="css-1yfbzum etth7i52">VBCH Area of Placement<span data-client-id="required_indicator" class="css-mfmuai etth7i53">*</span></legend>
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<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="Acute Care" tabindex="-1" data-client-value="Acute Care" data-client-id="radio_VBCH Area of Placement" type="radio" title="Acute Care" name="mdP7XaKD"
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<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="Specialty (please identify in 'other')" tabindex="-1" data-client-value="Specialty (please identify in 'other')"
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<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="Perioperative Services" tabindex="-1" data-client-value="Perioperative Services" data-client-id="radio_VBCH Area of Placement" type="radio"
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<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="Nursing Leadership" tabindex="-1" data-client-value="Nursing Leadership" data-client-id="radio_VBCH Area of Placement" type="radio"
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<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="Nursing Education" tabindex="-1" data-client-value="Nursing Education" data-client-id="radio_VBCH Area of Placement" type="radio"
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<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="Other" tabindex="-1" data-client-value="Other" data-client-id="radio_VBCH Area of Placement" type="radio" title="Other" name="mdP7XaKD"
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<div data-client-id="container_VBCH Other (please list)" data-client-type="text" id="nqGvL6M2" class="css-1e3khfm ef83ajd0"><label for="textarea_VBCH Other (please list)" data-client-id="label_VBCH Other (please list)"
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<div class="css-tkslta e1tmc1mx0">
<fieldset data-client-id="container_VTHH Area of Placement" data-client-type="radio" data-client-align="vertical" id="AJn2YKqw" class="css-110bzo0 etth7i50">
<legend data-client-id="label_VTHH Area of Placement" class="css-1yfbzum etth7i52">VTHH Area of Placement<span data-client-id="required_indicator" class="css-mfmuai etth7i53">*</span></legend>
<div class="css-ml5vzx etth7i51">
<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="Acute Care" tabindex="-1" data-client-value="Acute Care" data-client-id="radio_VTHH Area of Placement" type="radio" title="Acute Care" name="AJn2YKqw"
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<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="Critical Care (including ED)" tabindex="-1" data-client-value="Critical Care (including ED)" data-client-id="radio_VTHH Area of Placement" type="radio"
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<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="Specialty (please identify in 'other')" tabindex="-1" data-client-value="Specialty (please identify in 'other')"
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<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="Perioperative Services" tabindex="-1" data-client-value="Perioperative Services" data-client-id="radio_VTHH Area of Placement" type="radio"
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<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="Nursing Leadership" tabindex="-1" data-client-value="Nursing Leadership" data-client-id="radio_VTHH Area of Placement" type="radio"
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<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="Nursing Education" tabindex="-1" data-client-value="Nursing Education" data-client-id="radio_VTHH Area of Placement" type="radio"
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<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="Nursing Informatics" tabindex="-1" data-client-value="Nursing Informatics" data-client-id="radio_VTHH Area of Placement" type="radio"
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<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="Other" tabindex="-1" data-client-value="Other" data-client-id="radio_VTHH Area of Placement" type="radio" title="Other" name="AJn2YKqw"
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<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_VTHH Other (please list)" data-client-type="text" id="zq8zpz0D" class="css-1e3khfm ef83ajd0"><label for="textarea_VTHH Other (please list)" data-client-id="label_VTHH Other (please list)"
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<div class="css-1o5h39n e1tmc1mx0">
<fieldset data-client-id="container_Do you have a school issued photo ID badge?" data-client-type="radio" data-client-align="vertical" id="JzDbl7qW" class="css-110bzo0 etth7i50">
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<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="Yes" tabindex="0" data-client-value="Yes" data-client-id="radio_Do you have a school issued photo ID badge?" type="radio" title="Yes" name="JzDbl7qW"
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<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="No" tabindex="0" data-client-value="No" data-client-id="radio_Are you a current VUMC employee? " type="radio" title="No" name="Gzj8jPdJ"
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<div data-client-id="container_What is your VUMC ID?" data-client-type="text" id="OOEMaNlZ" class="css-1e3khfm ef83ajd0"><label for="text_box_What is your VUMC ID?" data-client-id="label_What is your VUMC ID?" class="css-1xl1v40 ekxsfat0">What is
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<div id="description_What_is_your_VUMC_ID_" class="rich-text-field-desc">
<p><em>Not your employee ID</em></p>
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<ul>
<li>Cover Letter and Resume</li>
<li>Unofficial Transcript (from current program)</li>
<li class="ql-indent-1">Must be complete unofficial transcript PDF, not copied to a word document or other form of documentation</li>
<li class="ql-indent-1">Full name included</li>
<li class="ql-indent-1">Grades for all semesters, including at least two semesters prior to semester of placement need, if possible</li>
<li class="ql-indent-1">Must be full unofficial transcript PDF</li>
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Student Placement Request Form Welcome to Student Placement! We are thrilled to have students complete their practicums/preceptorships at VUMC in various clinical practice areas, with a focus in advanced practice, nursing education, leadership, informatics, etc. Students, including current VUMC staff, please submit this placement request form according to the deadlines outlined on our website. Forms received following the deadlines may result in delayed start dates for approved rotations. Student Full Name* Student Date of Birth* Calendar IconCalendar Student School Email Address* School Name* Select Caret IconCaret symbol If you selected other, list school name here* Please note, if your school name is not listed above, VUMC does not have a current affiliation agreement with your institution and 6-8 weeks will be required to establish this agreement. School Contact Information* Contact to establish an Affiliation Agreement. -------------------------------------------------------------------------------- Are you an NP, PA or Midwifery Student?* Select or enter value Caret IconCaret symbol Type of Program for Advanced Practice Student* Select or enter value Caret IconCaret symbol Program Specialty* Select or enter value Caret IconCaret symbol Program Spcialty: Other* Program of Study* Select Caret IconCaret symbol Type of Program* Select or enter value Caret IconCaret symbol Program of Study: Other* Confirmed Preceptor Full Name* Please list: Name of Preceptor Preceptor Work Area If you have NOT identified a preceptor: Please know that the availability of preceptors is limited and based on your request and verification of preceptor willingness and availability. Please DO NOT submit this survey. If you have any further questions, please do not hesitate to contact us at student.placement@vumc.org. Confirmed Preceptor Credentials Select or enter value Caret IconCaret symbol Confirmed Preceptor Contact Information.* Please list your preceptor's VUMC Email Address Do you have a preferred preceptor?* Yes No Preferred Preceptor Full Name* Include preceptor information pertinent to the clinical area of interest. A new form must be submitted for each clinical area of interest. Please list: Name of Preceptor Preceptor Work Area Preferred Preceptors Credentials* Select or enter value Caret IconCaret symbol Other: Preferred Preceptor VUMC Email* Do you have a 2nd preferred preceptor?* Yes No 2nd Preferred Preceptors Full Name* Please list: Name of Preceptor Preceptor Work Area 2nd Preferred Preceptors Credentials* Select or enter value Caret IconCaret symbol 2nd Preferred Preceptor Other 2nd Preferred Preceptors VUMC Email* Research or quality improvement project required? Any human subjects research that takes place at VUMC will need to be submitted to the VUMC IRB. Please review the Research IRB Instructions for further information. **Please right click link and open in new window** Yes No Start Date* Calendar IconCalendar End Date* Calendar IconCalendar # of Hours Required to Complete* Facility* Vanderbilt University Adult Hospital (VUAH - Adult Inpatient Hospital) Monroe Carell Jr. Children's Hospital at Vanderbilt (Monroe Carell- includes inpatient and outpatient Children's) Vanderbilt Medical Group (VMG- Adult Outpatient Clinics) Vanderbilt Psychiatric Hospital (VPH) Vanderbilt Wilson County Hospital (VWCH) Vanderbilt Bedford Community Hospital (VBCH) Vanderbilt Tullahoma-Harton Hospital (VTHH) Inpatient or Outpatient Experience (preference)* Inpatient Outpatient Either is Acceptable VUAH Area of Placement* Acute Care Critical Care (including ED) Women's Health Specialty (please detail type of specialty below in ‘other’) Perioperative Services Nursing Leadership Nursing Education Nursing Informatics Other VUAH Other (please list) Monroe Carell Jr. Area of Placement* Acute Care Critical Care (PED, PCICU, PICU) NICU Pediatric Outpatient Specialty (please detail type of specialty below in ‘other’) Perioperative Services Nursing Leadership Nursing Education Nursing Informatics Other Monroe Carell Jr. Other (please list) Will you be required to wear scrubs in the OR? Select Caret IconCaret symbol What is your size (top and bottom)? VMG Area of Placement* Primary Care Family Medicine Women's Health Specialty (please detail type of specialty below in ‘other’) Nursing Leadership Nursing Education Nursing Informatics Other VMG Other (please list) VPH Area of Placement* Inpatient Outpatient Either is Acceptable Nursing Leadership Nursing Education Nursing Informatics VWCH Area of Placement* Acute Care Critical Care (including ED) Women's Health Specialty (please identify in 'other') Perioperative Services Nursing Leadership Nursing Education Nursing Informatics Other VWCH Other (please list) VBCH Area of Placement* Acute Care Critical Care (including ED) Women's Health Specialty (please identify in 'other') Perioperative Services Nursing Leadership Nursing Education Nursing Informatics Other VBCH Other (please list) VTHH Area of Placement* Acute Care Critical Care (including ED) Women's Health Specialty (please identify in 'other') Perioperative Services Nursing Leadership Nursing Education Nursing Informatics Other VTHH Other (please list) Do you have a school issued photo ID badge?* Yes No Are you a current VUMC employee? * Yes No What is your VUMC ID? Not your employee ID Clinical Coordinator Email Address* The individual responsible for verifying students meet facility compliance requirements Files to be uploaded* * Cover Letter and Resume * Unofficial Transcript (from current program) * Must be complete unofficial transcript PDF, not copied to a word document or other form of documentation * Full name included * Grades for all semesters, including at least two semesters prior to semester of placement need, if possible * Must be full unofficial transcript PDF * Is your course syllabus for this rotation available? If so, please upload documents. Drag and drop files here or browse files -------------------------------------------------------------------------------- Send me a copy of my responses Submit Powered by Smartsheet Modern Logo On Light Privacy Notice|Report Abuse