PROGRAM COORDINATORS for College / Residency / Advanced Practice Providers


STEP 1:  Complete the clinical/residency placement request process.

  1. You must have a current contract / affiliation verification (Updated 6/24/2022) with the health care 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 health care organization.
  2. Complete the clinical / residency placement request form (Updated 6/24/2022). This Excel form has two sheets; 1) Preceptor Requests, 2) Groups with Instructor Requests. For preceptorships, requests should be submitted 10-12 weeks before the clinical start date. If you haven’t heard back in a reasonable amount of time, please contact the facility representative directly.
  3. Email the completed form to the clinical/rotation agency contact.
  4. If approved, continue to Step 2. If denied, the facility will contact you.

For all Advocate Aurora undergraduate nursing requests, please see the AAH website:
Advocate Aurora Epic/Pyxis Request Form (for non-nursing students)Updated 10/23/2020
Laura Janssen (Inpatient Undergraduate Requests)
Kristine Kuhfuss (Preceptor Led Requests)
Any questions regarding graduate level, non-clinical students can be directed to:
Karen Ganey, Nursing Professional Development Specialist

STEP 2:  Complete the clinical/residency program placement process (after you receive approval).

  1. Complete and submit the affiliation verification (Updated 6/24/2022) form to the clinical agency contact. 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. Contact the clinical agency contact to insure computer access and training.

STEP 3: Complete the orientation modules.

Prior to working at a clinical site, the following orientation modules must be completed annually by students / residents / advanced practice providers / faculty. 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 modules – (Updated 6/24/2022) form. The school will retain the signed/dated forms. Do not submit this form 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


Student Evaluation of the Clinical Experience (Group or Precepted) (Reviewed 6/24/2022) Students are to complete this form and return it to their college 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.)

RN Preceptor Handbook Updated 9/23/2022
Preceptor Agreement Reviewed 9/23/2022
Preceptor Evaluation of the Precepted Clinical Experience Reviewed 9/23/2022

Epic & Pyxis Access Requests Reviewed 6/24/2022 – Listed below are emails where Epic access requests can be sent. For Advocate Aurora, please use their new ‘Advocate Aurora Epic/Pyxis Request Form’ located in step 1.
Epic Trained Instructors Updated 6/9/2022

ABMC – Epic
ABMC Epic Site-specific Resource 8/2/2022

BELLIN Health – Epic
Bellin Health Epic Site-specific Resource 8/2/2022 – Pyxis and glucose monitor requests also need to be requested at the same time and are included on the Epic email.
Glucose Monitor:

HSHS – Epic
HSHS Epic Site-specific Resource 8/2/2022
HSHS Epic Student Instructor Co-sign Handout 8/2/2022
HSHS Epic Student Nurse Clinical Instructor Outline 8/2/2022
Epic AccessHelp Desk –
HSHS Gaining Student Epic Access Updated 8/3/2022


Affiliation Verification Updated 6/24/2022
Background Approval Policy Reviewed 6/24/2022
Criminal Background Check Process Reviewed 6/24/2022
Clinical / Residency Placement Request Forms Updated 6/24/2022
Sheet 1:  Preceptor Requests
Sheet 2:  Groups with Instructors Requests
Confidentiality Agreement and Acknowledgement of Orientation Modules – Updated 6/24/2022
Hepatitis B Declination Reviewed 6/24/2022 – This form does not apply for Advocate Aurora.
Immunization & Health RequirementsReviewed 6/24/2022
Instructor Preclinical Checklist Updated 6/24/2022
Onsite Student / Advanced Practice Provider / Resident Orientation Checklist Reviewed 6/24/2022
COVID-19 Student-Faculty Communication ProcedureReviewed 6/24/2022

Student Assignments
Bellin CollegeReviewed 6/24/2022
NWTCReviewed 6/24/2022
Rasmussen UniversityReviewed 6/24/2022
UW – Green Bay Reviewed 6/24/2022
Student Evaluation of the Clinical Experience (Group or Precepted) Reviewed 6/24/2022