NUR448 COMMUNITY HEALTH NURSING CARING FOR THE PUBLIC’S HEALTH
Module 3 A2 SLEC Request and Approval Form Submission
Complete and submit the Service Learning Experience Clinical Request & Approval Form to your NUR448 Faculty Instructor for final approval.
You will submit this form to your NUR448Faculty Instructor during Module 3/Week 5 through the M3A2: SLEC Form Submission assignment dropbox.
Please note: final approval is required prior to contacting and setting up SLEC times with the agency.
All sections MUST be filled out.
Student Name: _______________________________________________________________________
Name of agency/organization/resource where SLEC will take place: _____________________________________________________________________________________
Name & title of contact individual/mentor at agency: _____________________________________________________________________________________
Contact information for SLEC site: _____________________________________________________________________________________
Street address City/State/Zip Code
_____________________________________________________________________________________
Phone number email address
Vulnerable PopulationServed: __________________________________________________________ _
Health People 2020 Goal and Objective addressed by agency: _____________________
____________________________________________________________________________________
Give a brief description of the agency&the services provided by this agency: ____________________
_____________________________________________________________________________________
___________________________________________________________________________________
Activitiesengaged to meet course outcomes: _______________________________________________
__________________________________________________________________________________________________________________________________________________________________________
Faculty Instructor’s Signature Date of Approval
If not approved reason: _______________________________________________________________
___________________________________________________________________________________
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