NUR 350 Clinical Practice Experience Acknowledgement Form

I confirm I am a nurse or healthcare provider who will be mentoring , a student at

Southern New Hampshire University, during her/his health education activity experience, as described
below at facility, and I will provide oversight of the experience.

This experience activity will consist of eight clinical practice hours utilizing the nursing process, when the
student will be required to assess a vulnerable population; diagnose a need; and then plan, implement, and
evaluate a health education activity as a response to the need.

Please note: Students will not be providing direct physical patient care. This activity should focus on
assessing a vulnerable population and providing education to healthcare professionals on this population. It is the
responsibility of the individual facility to provide HIPAA training as needed for the student.

Description of activity:

Date(s) and time(s) of health education activity:

Mentor full name and healthcare credentials (printed):

Title of mentor: _____

Contact information (phone/email):

Work: Cell: Email: _________________________

Mentor signature: Date:

Student signature: _ Date: ___

By signing above, I, the student, give permission for the course instructor to contact the mentor by phone or
email to check on my progress. The course instructor provides a digital signature upon the grading of the
Clinical Practice Experience Acknowledgement Form.