User: ()
Bridges to Excellence Experience - Intent to Visit
Form Instructions: Arrange observational visit with department/unit manager prior to completing this form. Submit form electronically to: HS-Center for Professional Practice of Nursing (hs-cppn@ucdavis.edu)
* Required
Demographics
*1. Name ( Last, First)
*2. PPS/Badge #:(ex: UC000111999)
*3. Today's Date:
*4. Department/Unit
*5. Department manager/supervisor
Observational Experience
Section Instructions: Provide information concerning your upcoming observational experience. If you do not know Preceptor's name, leave blank.
*6. Expected Date(s) of observation
(MM/DD/YYYY)
*7. Observational Unit/Department Manager
*8. Observational Unit/Department:
9. Assigned Preceptor:
Personal Objectives/Goals
Section Instructions: What do you wish to learn, contrast, evaluate, identify during this experience? What will you do to achieve your goals? Discuss with your mentor and or nursing manager of visiting unit.
*10. Personal Learning Objectives/Goals:
Max Characters: 1000
Professional Leave
Section Instructions: Professional Leave is granted through your manager, but CPPN would like to know if:
*11. Have you requested to use Professional Leave for your Bridges to Excellence experience?
12. Has your Professional Leave Time request been approved by your manager?
OPTIONAL Please enter your email address if you wish to receive a copy of the form data that you are submitting: