PM-DNP Agency Request Form

Please read instructions before completing form. Students are responsible for ensuring accuracy of information provided. Inaccurate information will delay the process and may impact on the student's ability to progress in the program. It is recommended the student submit this form least 3 weeks prior to anticipated start date. Students cannot begin clinical until notified via Marshall University email that an affiliation agreement with the agency is in place. Clinical hours completed before the affiliation agreement is in place will not be counted towards the course requirement. Additionally, the student is not covered by University malpractice insurance without a signed agency affiliation agreement in place.

I have read all instructions and information before completing this form:

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Student's Name

First Last

Date Submitted for Processing:

Student ID Number (MUID)

Student Phone Number(s)

Course Number NUR 800, NUR 804, NUR 808, NUR 812

Semester

Clinical Navigator Name

First Last

Credentials MD/DO/NP or other (please specify)

Hours are requested for:

Agency Name

Agency Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Agency Contact Person

First Last

Agency Phone Number

Clinical Navigator's Email