Carroll Community College ‘Nursing Program ‘Nursing Student Practicum Schedule i f form Sections: Student to complete this form with preceptor during the first week of practicum, then email a oF Oh ‘to faculty triad partner no later than the end of the first week. Remember: Total hours required = 120. If any cl bet a ‘the schedule occurs during the preceptorship, a revised copy ofthis form needs to be submitted to the faculty tria partner Megan Knodes LOUYEN Nai = 20) yoy 407 ¥ Print student name Print preceptor name and phone number Fredevic k Memoria Float putt Name of facility/hospital Name of specific unit Unit phone number Scheduled Day ‘Hours scheduled Number of hrs, Additional Information L mm/dd/yy (e.g., 0630-1830) {e.g., 12 hrs.) ‘laqvon OUD 195 (LY oe : PANN |_qus-\a\5 \1 ‘1\y3\100 - ye \ Oou= 1215 TL Va edy 215 \2021 OWN “1015 \2 e M Mice ryn_M eet: fasta | ouu5-m)5 vg ol, — MeSOr00 By 12024 ouus- J9% ae {3412021 Our |S yw [3)to\202\ Owy-i4ie | 2 PT S\e\vy1\ OW5-\5, n Bii\2001 | owWe-1915 FS eA cg Final meets 2\t\\1 Gro0 ‘Additional schedule information may be added on reverse side, TOTAL HOURS: Updated Sp 2018: Sp 2019 jm Scanned with CamScanner