Practicum Site Information Form
STUDENT INFORMATION
Student name:
Student phone number (primary):
City/town: N
State:
Walden email address:
Alternative email address:
Time zone: MST: Practicum Site Information Form
Student practicum site schedule: see below*
PRECEPTOR AND SITE INFORMATION
Preceptor name (first and last):
Preceptor credentials (MD, FNP, DO, etc.): FNPC, PMHNP
Site name:
Site address
City/town:
State: Arizona
Preceptor email address
Preceptor phone number:
Site phone number:
Field Site Clinic hours: Wednesday and Friday for the first week and Thursdays and Fridays for subsequent weeks. The clinical hours will be from 9:00 AM to 5:00 PM.
November: 27th, 29th
December: 5th, 6th, 12th, 13th, 19th, 20th, 26th, 27th
January: 2nd, 3rd, 9th, 10th, 16th,17th, 23rd, 24th, 30th,31st
*You must have specific dates and times, please provide a calendar with your dates and times written in the days of the week. We must be able to verify the exact dates you are in practicum setting. We must be able to see you will meet your hour requirements including holidays off: Simply stating every Monday for 8 hours will not be acceptable.
Month#1: November
| Clinical Week | Time (Wednesday) | Time (Friday) |
| CW-1 (27th-29th) | 9 am-5 pm | 9 am-5 pm |
Month#2: December
| Time (Thursday) | Time (Friday) | |
| CW-2 (5th-6th) | 9am-5pm | 9am-5pm |
| CW-3 (12th-13th) | 9am-5pm | 9am-5pm |
| CW-4 (19th-20th) | 9am-5pm | 9am-5pm |
| CW-5 (26th-27th) | 9am-5pm | 9am-5pm |
Month#3: January, 2025
| Time (Thursday) | Time (Friday) | |
| CW- 6 (2nd-3rd) | 9am-5pm | 9am-5pm |
| CW-7 (9th-10th) | 9am-5pm | 9am-5pm |
| CW-8 (16th-17th) | 9am-5pm | 9am-5pm |
| CW-9 (23rd-24th) | 9am-5pm | 9am-5pm |
| CW-10 (30th-31st) | 9am-5pm | 9am-5pm |
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Practicum Site Information Form
STUDENT INFORMATION
Student name:
Student phone number (primary):
City/town:
State:
Walden email address:
Alternative email address:
Time zone:
Student practicum site schedule: see below*
PRECEPTOR AND SITE INFORMATION
Preceptor name (first and last):
Preceptor credentials (MD, FNP, DO, etc.):
Site name:
Site address:
City/town:
State:
Practicum Site Information Form
Preceptor email address:
Preceptor phone number:
Site phone number:
Field Site Clinic hours:
*You must have specific dates and times, please provide a calendar with your dates and times written in the days of the week. We must be able to verify the exact dates you are in practicum setting. We must be able to see you will meet your hour requirements including holidays off. Simply stating every Monday for 8 hours is not acceptable.