Clinical Site Preference Form

The University of Iowa
Graduate Program in Rehabilitation
Approved Clinical Site Request Form

Please fill out the information and list three clinical site preferences from the clinical site listing. Provide a hard copy to Dr.Saunders by October 15th.

First Name:
Last Name:
E-mail address:
Home Phone:
Work Phone:
Mailing Address:
City:
State:
Zip:
Area of Specialization:
Semeter and year for which you desire a clinical placement:
Course Number for which placement:

Clinical Site Preferences

List your three preferred clinical sites from the approved clinical site listing.
*Do not contact agencies on your own. The Clinical Supervisor is responsible for making the final placement site decision.

Agency 1:
Contact person
Address of Site
Phone:
Rationale for choice

Agency 2:
Contact person
Address of Site
Phone:
Rationale for choice

Agency 3:
Contact person
Address of Site
Phone:
Rationale for choice

Will you have transportation available during the semester you are enrolled in clinical experience:

Yes

Are there any additional factors which should be considered in selecting a clinical site?

Please describe any previous work experience that you believe to be relevant to selection of a clinical site.

Please briefly describe your needs in supervision.

List below a statement of your goals for the clinical experience:

If you are a student who requires accommodations please describe your needs below:

*Submit proof of Liability Insurance to Dr. Maki*

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