Nursing Project Application

All students completing any kind of project or research study at Gundersen Health System must have Human Subjects oversight. You must have your cover letter or introductory letter and resume documents available to send via email once you complete this application. As your project gets closer, you must submit the Student Project Template. Completion of this application does not guarantee that your project will be approved.

NOTE: If you are in need of a project or research study AND clinical hours, please complete the application for clinical hours instead of this application. You can include your project request in that application.

Completion of this application does not guarantee that your project will be approved.

Please understand you must go through the Medical Education department to request your project proposal in any Gundersen Health System facility.

The appropriate contractual Affiliation Agreements for Gundersen Health System must be in place prior to clinical placement. If a contract is needed with the school/university for student placement, please note:

This process can be lengthy and does not guarantee student placement
There is no guarantee that a contract will be successfully negotiated
Student cannot be placed or start a project until contract is in place

Basic information

Your name

Phone

Address

Address 2

City/town

State/province

ZIP/postal code

Country

Are you a current Gundersen employee?

Yes

School information

School name

Address

Address 2

City/town

State/province

ZIP/postal code

Country

School program

Name of school contact/program coordinator

Email address of school contact/program coordinator

Phone number of school contact/program coordinator

Expected graduation date

Licensure

In order to complete clinicals at GHS, you MUST have a valid RN licensure that will not expire during your clinicals. Your licensure MUST be from a Compact State at the time of submitting this application.

RN licensure state

RN licensure number

RN licensure expiration date

RN licensure name, if different than first and last name listed on this application

Student project

Anticipated project start and end dates

Anticipated project start and end dates
	Anticipated project start and end dates	Item weight

more items

Project hours needed

Why are you interested in completing a project through the Gundersen organization?

Do you have a facilitator/champion/mentor in mind that you would like to reach out to?

Yes

Name of the possible facilitator/champion/mentor you would like us to contact

Terms of application

By typing my name below, I acknowledge that all nursing project requests must come through the Medical Education department. I understand that an affiliation agreement needs to be in place between my school and Gundersen. I also understand my student project ideas must be discussed with the Nursing Research team early in the planning process; must be vetted by the Gundersen project vetting committee; and my project must be reviewed by the Human Subjects Review Board to receive approval/exemption status prior to starting any project work.

A friendly reminder: Do not reach out to providers on your own. Placement must go through Medical Education. Thank you.

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