proposal - New Record

Begin a New Site Proposal

Note: all online Clerkship Site Proposals must have a Proposal ID#.

New Proposals must also include your name (entered the same as your log-in) and PIN# in the spaces provided. Please email Professor Dahm (sdahm@ku.edu) when you have submitted a new proposal. Site proposals must be submitted for approval at least 2 weeks before you plan to proceed with on-site activity.

Student:

Password (PIN#):

Proposal ID#:

Date:

Student Email:

Student Phone:

Proposed Site Name:

Is this site affiliated with your place of employment in any way?

***If yes, please email a detailed description of how this clerkship will differ from your employment responsibilities to sdahm@ku.edu

Proposed Clerkship Title:

Proposed Site Street Address:

City:

State:

Zip:

Proposed Preceptor Name:

Proposed Preceptor Phone:

Proposed Preceptor Email:

Proposed Preceptor Degree: (Pharm.D., B.S.P., M.D., D.O., R.N., A.R.N.P., P.A.)

How many years has the proposed preceptor been licensed?

Proposed preceptor's additional qualifications (certificates, residencies, fellowships):

How long do you anticipate this clerkship will take you to complete (must be > 4 weeks and < 4 months, with a recommended maximum of 12 weeks)?

** I understand that if this clerkship is not completed in a maximum of 4 months I will have to drop the course and enroll again. (Yes or No)

When is your desired start date for this clerkship (mm/dd/yr)? (must be at least 2 weeks after completed proposal is received by NTPD office)

What will the completion date be if you start on your desired date (mm/dd/yr)?

How many portfolios do you anticipate completing in this clerkship?

Will this be your linear care clerkship? (Yes or No)

My immunization documentation has been confirmed by the NTPD office as complete (Yes or No)
**This proposal cannot be reviewed if immunization documentation has not been confirmed by the NTPD office - this means documentation of immunizations or immunity as requested on the Immunization and Insurance Information Form.

For a Site Proposal to be considered, you must email Professor Dahm (sdahm@ku.edu) when you have completed this submission!

It is highly recommended that you PRINT this page before pressing the "submit" button.

(this form is for reference only, not for actual submission)

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Student:		Password (PIN#):
Proposal ID#:		Date:
Student Email:		Student Phone:
Proposed Site Name:
Is this site affiliated with your place of employment in any way?
***If yes, please email a detailed description of how this clerkship will differ from your employment responsibilities to sdahm@ku.edu
Proposed Clerkship Title:
Proposed Site Street Address:
City:		State:
		Zip:
Proposed Preceptor Name:
Proposed Preceptor Phone:		Proposed Preceptor Email:
Proposed Preceptor Degree: (Pharm.D., B.S.P., M.D., D.O., R.N., A.R.N.P., P.A.)
How many years has the proposed preceptor been licensed?
Proposed preceptor's additional qualifications (certificates, residencies, fellowships):
How long do you anticipate this clerkship will take you to complete (must be > 4 weeks and < 4 months, with a recommended maximum of 12 weeks)?
** I understand that if this clerkship is not completed in a maximum of 4 months I will have to drop the course and enroll again. (Yes or No)
When is your desired start date for this clerkship (mm/dd/yr)? (must be at least 2 weeks after completed proposal is received by NTPD office)
What will the completion date be if you start on your desired date (mm/dd/yr)?
How many portfolios do you anticipate completing in this clerkship?
Will this be your linear care clerkship? (Yes or No)
My immunization documentation has been confirmed by the NTPD office as complete (Yes or No) **This proposal cannot be reviewed if immunization documentation has not been confirmed by the NTPD office - this means documentation of immunizations or immunity as requested on the Immunization and Insurance Information Form.