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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? Select Yes No 12. Has your Professional Leave Time request been approved by your manager? Select Yes No OPTIONAL Please enter your email address if you wish to receive a copy of the form data that you are submitting: ClearSubmit