STUDENT RESEARCH PRACTICUM POLICY
STUDENT RESEARCH PRACTICUM REQUEST FORM
Massachusetts General Hospital
The Yvonne L. Munn Center for Nursing Research
A. Please provide the following information
Student Name:_________________________________________________ DOB: __________
Telephone: _________________________________ Fax: ___________________________
E-mail: _______________________________________________________________________
RN Mass License #: _______________________________________ Exp. Date: __________
Professional Liability Insurance #: ___________________________ Exp. Date:__________
Partners CITI Certification (Human Subject Protection): Date course taken: ____________
Employee (Institution):__________________________________________________________
B. Please provide the following information
School: _______________________________________________________________________
Program: BSN_____ NP _______ MSN/CNS______ PhD ______
DNP ______ Other____________________
Course number: ______________________________________________________________________
Semester during which project/practicum will be conducted:
Fall _________ Winter/Spring __________ Summer __________
Dates of project/practicum: From: _________________________To: __________________________
Total # of hours required for course: _____________________________________________
C. Please provide the following information
What type of Research Practicum are you seeking (please circle 1, 2 Or 3 & complete the requested information)?
1. Work with a Researcher at MGH to learn research skills
A. Do you have prior research experience? If yes, please describe: ____________________________________________________________________________________________________________________________________________________________________
B. Please describe the research experience you are interested in (population, methods, skills, etc.)
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
2. Conduct a research project
A. Please write the title of your research project: ____________________________________________________________________________________________________________________________________________________________________
B. Please attach a 1 page document that lists the research question, specific aims of the project, brief overview of the methods and subject population of interest.
C. Please provide the IRB review date for your project (this includes approval or exempt status)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
3. Other experience; Please describe the student role: ________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________
D. Please provide the following information
Faculty Supervisor Name: _______________________________________________________
Telephone: ___________________________________ Fax: __________________________
E-mail: ______________________________________________________________________
Address: _____________________________________________________________________
Faculty Signature: _____________________________________________Date ____________
Role: Guidance across entire research process and provides final grade
Clinical Placement Coordinator Name:_________________________________________
Telephone: ___________________________________________________________________
E-mail: ______________________________________________________________________
Address: _____________________________________________________________________
Signature: _____________________________________________Date ____________
CCP Placement #:_________________________________________
Role: Works with student, institution and Program Development Manager at MGH to coordinate administrative logistics regarding the experience.
MGH Preceptor Name: ______________________________________________________________
Address: ______________________________________________________________________
Telephone: ____________________________________________________________________
E-mail: ______________________________________________________________________
Preceptor Signature: ___________________________________________ Date ____________
Role: Provides experience
***Preceptor will notify the Nursing Director about this study and communicate with Faculty about research study goals.
Please return this form, course syllabus, and CITI certification form to:
Linda Lyster Fax: (617) 724-3496
Administrative staff Phone: (617) 643-0431
Yvonne L. Munn Center for Nursing Research E-mail: llyster@
Massachusetts General Hospital
125 Nashua Street, 125 Nashua St. Suite 763
Boston MA 02114-1101
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