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

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download