University Clinical Field Experience Verification Form

University Clinical Field Experience Verification Form
Please complete this form to verify and document your clinical field experience for university records.
Student Full Name
First NameLast Name
Student Email Address
example@example.com
Student Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Academic Program or Major
Clinical Site Name
Clinical Site Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Clinical Supervisor Full Name
First NameLast Name
Clinical Supervisor Email Address
example@example.com
Start Date of Clinical Experience
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
End Date of Clinical Experience
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Total Number of Clinical Hours Completed
Brief Description of Clinical Duties and Activities Performed
Supervisor Evaluation of Student Performance
Rows Excellent Good Satisfactory Needs Improvement
Professionalism
Clinical Skills
Communication
Punctuality
Teamwork
Additional Comments by Supervisor (optional)
Supervisor Signature
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