Clinical Placement Information Form - Spring 2010

This form covers clinical placement from January 2010 to May 2010
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  • Course Information

    If your track, course, or instructor/advisor are not listed below, please contact the Dean's Office

  • Spring 2010

  • Be sure to choose the correct section number

  • If you know who your clinical instructor is, please enter them here

  • Preceptor Information

  • More than one Preceptor? Enter one here. List the rest below in the comment box.


  • Certain Sites may require an additional drug screening before they will accept you. Charges may apply.
    Please note: that even if your clinical placement form is approved, you can not begin clinical until you have completed a drug screen if required by your institution.
    Atlantic Health Systems
    This site requires that you get drug testing

    Newark Students can pick up the forms in Enrollment Services, SSB 152
    Stratford Students - pick up the forms in UEC 2025
    Please submit an authorization to disclose results
    Christian Health Care

    Paperwork has to be filled out

    • 2009 Self Learn Orientation Program Pre- test & Policies Procedure acknowledgement Page

    • Policy Code: of Ethics Legal  Behavior

    • 2009 CHCC Self  Learn Orientation Program

    East Orange General

    Paperwork has to be filled out

    • Atteststation Packet that has to be filled out prior to going to clinical site

    Englewood Medical Center
    This site requires that you get drug testing

    Newark Students can pick up the forms in Enrollment Services, SSB 152
    Stratford Students - pick up the forms in UEC 2025
    Please submit an authorization to disclose results
    Our Lady of Lourdes Medical Center
    • Education Affiliation Health Information Form

    Somerset Medical Center
    • Student Acknowledgment and Consent Form

    St. Michaels
    This site requires that you get drug testing

    Newark Students can pick up the forms in Enrollment Services, SSB 152
    Stratford Students - pick up the forms in UEC 2025
    Please submit an authorization to disclose results
    St. Peters Medical Center
    This site requires that you get drug testing

    Newark Students can pick up the forms in Enrollment Services, SSB 152
    Stratford Students - pick up the forms in UEC 2025
    Please submit an authorization to disclose results
    St. Clares Hospital
    This site requires that you get drug testing

    Newark Students can pick up the forms in Enrollment Services, SSB 152
    Stratford Students - pick up the forms in UEC 2025
    Please submit an authorization to disclose results
    St. Lukes Hospital
    This site requires that you get drug testing

    Newark Students can pick up the forms in Enrollment Services, SSB 152
    Stratford Students - pick up the forms in UEC 2025
    Please submit an authorization to disclose results
    Trenton Psychiatric Hospital
    This site requires requires a disclosure form be signed prior to clinical

    Newark Students can pick up the forms in Enrollment Services, SSB 152
    Stratford Students - pick up the forms in UEC 2025
    Visiting Nurses of Central New Jersey
    This site requires that you get drug testing

    Newark Students can pick up the forms in Enrollment Services, SSB 152
    Stratford Students - pick up the forms in UEC 2025
    Please submit an authorization to disclose results
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  • Student Information

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  • @umdnj.edu

    Only your official UMDNJ e-mail will be accepted. Please enter it properly

  • Yes
    No
  • Locker combo:

    If you have multiple precepters at the same location, please enter them here.

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