Fillable Arizona State Board of Nursing (Arizona State Board of Nursing)

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Arizona State Board of Nursing (Arizona State Board of Nursing)

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BROWSE ARIZONA STATE BOARD OF NURSING (AZ) FORMS

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Doug Ducey Joey Ridenour
Governor
Executive Director
Arizona State Board of Nursing
CLINICAL COMMITMENT FORM
Programs seeking provisional approval or to expand capacity need to complete one form for each clinical health care
facility where new or additional students will be placed for 2 years. The information contained in this form will provide
evidence for the Board to determine if the program meets the requirements of R4-19-207(D)(2)(f) for provisional approval
applicants and R4-19-209 (B)(1) for existing program applicants.
PROGRAM INFORMATION
Name of Program
Website
Institutional and Program Accreditation
Degree Awarded
Name of Program Director
Email Address
Address
City
State
Zip
Telephone
Number
Email Address
Anticipated Date of First Clinical Placement
Signature of Program Director/Designee
Date
Contact Number
Email Address
Fully describe your clinical needs for this facility for the first 2 years of placement including: 1) the anticipated
number of students needing placement in this facility; 2) type of clinical unit(s) for placement(s); 3) time and day
of placement; and 4) frequency of placements including dates.
Clinical Commitment Form
Page 2
Name of Agency
Address
City
State
Zip
License Type
Total Number of Beds (if applicable)
Maternity
Beds
Medical
Surgical Beds
Pediatric
Beds
Critical Care
Beds
Psych Mental
Health Beds
Others
Average Daily Census
Winter
Summer
NURSING STUDENT PLACEMENT COORDINATOR OF THE FACILITY
I have reviewed the full statement of clinical needs by the above-referenced program and agree to meet the
clinical placement needs as described. By signing this document I believe that the clinical placements
described by the program will be available when needed and that the agency is committed to placement of
students as planned.
Signature of Nursing Student Placement Coordinator Title Date
Signature of Chief Nursing Officer or Designee Telephone Number E-mail Address
Copies Provided to: Nursing Program
Clinical Agency
Arizona State Board of Nursing
CLINICAL AGENCY INFORMATION
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Arizona State Board of Nursing (Arizona State Board of Nursing)

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Completed 12 August 2020

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