Please complete this secure form. All of your answers are confidential and used internally for practice agreement with our legal team and reporting to the Accreditation Commission, CCNE and Kansas State Board of Nursing.

Please note the student may not begin this clinical rotation until this form is submitted and our Placement Coordinator has verified a contract is in place with your facility.

If you have any questions, please contact Carmen Carter, Senior Coordinator Practice Placement,

Thank you!

The University of Kansas School of Nursing Faculty and Staff

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