PROGRAM COORDINATORS for College / Residency / Advanced Practice Providers

Centers for Disease Control and Prevention “CDC is the nation’s health protection agency, working 24/7 to protect America from health and safety threats, both foreign and domestic. CDC increases the health security of our nation.”


STEP 1:  Complete the Clinical/Residency Placement Request Process

  1. You must have a current contract/affiliation agreement with the healthcare organization to proceed.  Please check with your school/residency program reps to confirm whether or not your school/residency program has a current affiliation agreement with the healthcare organization.
  2. Complete the clinical/residency program placement request form (see below). This Excel form has two sheets; 1) Preceptor Requests, 2) Groups with Instructors.
  3. For preceptorships, requests should be submitted 10-12 weeks before the clinical start date.
  4. If you haven’t heard back in a reasonable amount of time, please contact the facility representative directly.
  5. Email the completed form to the contact person listed on the ‘Contacts’ link below.
  6. If approved, continue to Step 2.
  7. If denied, the facility will contact you.

STEP 2:  Complete the Clinical/Residency Program Placement Process (after you receive approval)

  1. Complete and submit the affiliation verification form (see below) to the clinical/rotation site. Form is to be submitted on or by the clinical/residency program start date and no more than two weeks before the clinical/residency program start date.
  2. After all of the modules below are completed, maintain in the school files the signed/dated confidentiality agreement and acknowledgement of orientation modules (see below). (For Residents: Click the ‘Residents’ tab under the ‘Clinicals/Rotations’ drop-down menu for their learning modules and confidentiality agreement, etc.)
  3. Contact the clinical/rotation site to insure computer access and training.

STEP 3: Faculty should submit the student completed ‘Student Evaluation of the Clinical Site OR Precepted Clinical’ forms to the healthcare facility’s clinical site coordinator no later than TWO WEEKS after completion of the clinical(Resident coordinators: See ‘Residents’ webpage for ‘Evaluation of Rotation Site’ form to be completed by residents.)

Prior to working at a clinical site, the following Orientation Modules must be completed annually by students/residents/faculty members. After completing all four modules and you understand the information presented, complete, sign, and submit to your school or faculty member the ‘Confidentiality Agreement and Acknowledgement of Orientation Learning Modules‘ form. The school will retain the signed/dated forms. Do not submit the forms to the health care facility.


  1. HIPAA Privacy & Security – Updated 3/25/2022
  2. Infection Prevention – Updated 3/25/2022
  3. Professional Expectations in the Workplace – Updated 3/25/2022
  4. Safety in the Workplace – Updated 3/25/2022

General forms were reviewed by the GGBHA on 6/25/2021.
Affiliation Verification Updated 9/24/2021
Background Approval Policy Updated 6/25/2021
Criminal Background Check Process Updated 6/25/2021
Clinical Placement Request Forms Updated 6/25/2021
Sheet 1:  Preceptor Requests
Sheet 2:  Groups with Instructors
Confidentiality Agreement and Acknowledgement of Orientation Modules – Updated 6/25/2021
Hepatitis B Declination Updated 6/25/2021
Immunization & Health RequirementsUpdated 9/24/2021
Instructor Preclinical Checklist Updated 6/25/2021
Onsite Student / Advanced Practice Provider / Resident Orientation Checklist Updated 6/25/2021
COVID-19 Student-Faculty Communication ProcedureNew 8/12/2020

Bellin CollegeUpdated 10/23/2020
NWTCUpdated 10/23/2020
Rasmussen University – Updated 6/18/2021
UW Green Bay Updated 10/23/2020
Student Evaluation of the Clinical Experience (Group or Precepted) Updated 6/25/2021 – At the completion of a clinical experience, students are to complete this form and return it to their college or university instructor.  Faculty should submit the completed ‘Student Evaluation of the Clinical Experience (Group or Precepted)’ forms to the healthcare facility’s clinical site coordinator no later than TWO WEEKS after completion of the clinical. (Resident coordinators see ‘Residents’ webpage for ‘Evaluation of Rotation Site’ form to be completed by residents.)
CPR & CPR Renewal – American Heart Association BLS training must be completed within the last two years. Heartsaver and online-only training without a classroom skills component are not acceptable.
Epic Site Training Handouts Site Specific Training Sheets for ABMC, HSHS, Bellin – Added 2/3/2021
Epic & Pyxis Access Requests Updated 6/25/2021 – Listed below are emails where Epic access requests can be sent. For Aurora, please use their new ‘Advocate Aurora Epic/Pyxis Request Form’ linked below.
Epic Trained Instructors Updated 5/3/2022

Advocate Aurora Epic/Pyxis Request Form Updated 10/23/2020
Laura Janssen (Inpatient Undergraduate Requests)
Any questions regarding graduate level, non-clinical students can be directed to:
Karen Ganey, Nursing Professional Development Specialist

Epic: Student Modules & E-Learnings – PLEASE NOTE: These files require a password to open. User IDs and passwords can be obtained from Laura Janssen (not Karen Ganey as indicated on Aurora’s website).

BELLIN – Pyxis and glucose monitor requests also need to be requested at the same time and are included on the Epic email.
Glucose Monitor:

Epic AccessHelp Desk –
Gaining Epic Access at HSHS 10/26/2017
RN Preceptor Handbook Updated 10/22/2021
Preceptor Agreement Updated 10/22/2021
Preceptor Evaluation of the Precepted Clinical Experience Updated 10/22/2021
Contacts –  Utilize the Excel tabs to access specific contact groups. Updated 5/9/2022