NCHD Nursing Student Request Form
Use this form to request a practicum, internship or other field experience with the North Central Health District. While not all questions are required, the more information we have the better we will be able to work with you. Not all requests can be honored, as staff and projects change over time. Once your request is complete, please email your resume to jessica.pearson-spikes@dph.ga.gov.Important Notice: We currently cannot accept medical assistant, lab technician, or nurse practitioner students, due to staffing.
Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Academic Information
Please summarize the course requirements/goals here.
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What degree level will this field experience be applied to? For other degrees, or if it is not directly related to a degree, please choose "Other" and explain. At this time we are unable to accommodate Nurse Practitioner (NP) Students.
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Licensed Practical Nurse (LPN)
Associate Degree in Nursing (ADN)
Bachelor of Science in Nursing (BSN)
Nurse Practitioner (NP)
Other
School/College
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Field Experience Information
What type of experience level do you want or need? Practicum/Internship/residency/clinical/volunteer/etc
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How many hours are required? This is the total # of hours required over the entire length of the internship, NOT the hours per day or week.
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Proposed start date and end date for field experience. When would you like to start your field experience? Actual start date may change, this just gives us an idea of when you would be available.
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Month
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Day
Year
Date
Comments/Additional Information: Enter any additional information or clarify any answers from above
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Additional Background and Interests
This section is used to help us determine if we can adequately assist you in your program of study and place you with a a program or project.
Please explain why you are interested in completing your field experience with the North Central Health District
List any computer software programs you are proficient in using. Include MS Office programs, statistical packages, design experience, etc. If you feel you have high level skills in a particular program, please indicate that as well.
Have you used an electronic medical record system in any of your rotations?
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Yes
No
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Availability
Thinking about your schedule DURING the time you will be working on your internship: for each day indicate when you would be AVAILABLE (e.g.: 8am to 1pm) to be at your field experience. Keep in mind, most offices are open Mon-Fri 8am-5pm. If you are not available on a specific day, please list "N/A" or "Not Available". This helps us determine if your schedule with fit with the various programs. Some programs prefer students be available during specific time periods. We require all students to be available a minimum of 10 hours a week.
Monday
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Tuesday
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Wednesday
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Thursday
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Friday
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Weekends
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Is there a particular location that you would prefer to work? (Select all that apply) The North Central Health District covers a 13-county area in middle Georgia. Most programs are at the district office but nursing and environmental health are in each county (with some additional programs in Houston and Bibb).
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District Office (BBT Building Macon)
Baldwin County
Crawford County
Hancock County
Houston County
Jasper County
Jones County
Macon-Bibb County
Monroe County
Peach County
Putnam County
Twiggs County
Washington County
Wilkinson County
Is there any other information that you would like us to know? List any special needs, requirements, or accommodations that may be needed.
Submit
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