Nursing & Health Sciences

NHS Clinical Agreement Request Form


Date: _____________________________ Requested By: ______________________________

Facility/Agency Name                                                                 
P.O. Box  

Contact Person-Name & Title

(person you spoke with at the facility)


Phone Number

(of Contact Person-optional)

Fax Number-optional  
E-Mail Address  

Authorized Person-Name & Title

(person who will sign the contract)

Source of Contract:  Will we send an NHS contract or does the agency require that we sign theirs?  If we must sign theirs, what is the rationale for this?  What issues appear in the agency's contract that may impact the student (EX: Additional immunizations, background check, drug testing)?  What additional requirements are there for the NHS (Letter of Understanding)?

** When you request a new contract, ALL the above information is needed.