Clinical Placement Information Form
Graduate Programs Fall 2017

For clinical placement - September 5, 2017 to December 22, 2017

Before completing the Clinical Placement Form please check to make sure you have completed all clinical clearance requirements. All requirements must be complete to participate in clinical. View Details

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Clinical Placement Information

  • Course Information

    If your track, course, or instructor/advisor are not listed below, please contact Sherri Moose at:
  • Fall 2017

  • Be sure to choose the correct section number:

  • If you know who your clinical instructor is, please enter them here

  • Preceptor Information

  • More than one Preceptor? Enter one here. List the rest below in the comment box.

  • Prevent common form errors: Don't use the Ampersand (&) or slash (/) in these boxes

  • - -
  • - -
  • Student Information

  • - -

    (Enter your NetID in this box) - Your Rutgers email is If you don't have an address, contact Sherri Moose at

  • Yes
  • Locker combo:

    If you have multiple preceptors at the same location, please enter them here.

  • By submitting this form, I acknowledge that it is my responsibility and that I attest that I am in full compliance with Rutgers SN Student Health Requirements. Furthermore, I understand that it is my responsibility to ensure that I am in compliance with all requirements of the host facility, up to and including (if required) completion of an updated criminal background check and/or drug screening. Lastly, I acknowledge and agree to comply with the practice that all University and host facility requirements are completely and satisfactorily fulfilled and that the clinical preceptor letter has been signed and returned to Rutgers prior to the start of my clinical rotation.

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