Complete and submit the “Provider Interview Acknowledgement Form” prior to conducting your interview for the Community Assessment and Analysis Presentation assignment.

The “Provider Interview Acknowledgement Form” is a clinical document that is necessary to meet clinical requirements for this course. Therefore, the acknowledgement form should be submitted with the provider’s hand-written signature. A typed, electronic signature will not be accepted.

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Provider Interview Acknowledgement Form

Student Name: __________________

Section & Faculty Name:_________________________________

Date of Interview: ________________

Provider Information

Provider Name :

Last

First

M.I.

Credentials:

Title:

(i.e. MS, RN, etc.)

Organization:

Phone Number:

E-mail Address:

Interview Acknowledgement

I _______________________acknowledge that I was interviewed by _____________________on the

(Provider Name) (Student Name)

date listed above. The organization / agency does not endorse the university or the student however, the student learning experience is considered appropriate for educational purposes.

______________________________ _________________

Provider Signature Date Signed

NOTE:

Acknowledgement form is to be returned to the student for electronic submission to the faculty member.

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