BSN 423 Fall Clinical Application

This application is for Dominguez Hills students who are requesting to take BSN 423 to obtain clinical hours for the BSN Degree.

Pre-requisites to BSN 423 are BSN 380/382 & 381 (Health Assessment & lab) & BSN 346 (Pathophysiology)

1. CSUDH Student ID# *This question is required.

2. First Name *This question is required.

3. Last Name *This question is required.

4. Street Address *This question is required.

5. City *This question is required.

6. State *This question is required.

7. Zip code *This question is required.

8. In which county do you reside? *This question is required.

Please enter an 'other' value for this selection.

9. Toro email address (personal email addresses will not be accepted) *This question is required. This question requires a valid email address.

10. Phone number *This question is required.

11. Date of Birth *This question is required.

12. RN License number (Interim Permits are not acceptable) *This question is required.

13. Please upload a PDF copy of your license verification, with today's date, from the BRN website: RN License Verification (Interim Permits not acceptable) *This question is required.

File: {{filename}} delete

14. Please upload a PDF copy of your current Resume *This question is required.

File: {{filename}} delete

15. What term and year do you anticipate graduating with your BSN? (Ex: Fall 2024, Spring 2025) *This question is required.

17. Please select the statements below which are true for you: *This question is required.

I am interested in pursuing a career as a School District Nurse.
I am interested in pursuing a career as a Public Health Nurse.
I am only taking BSN 423 to fulfill my BSN requirements.

18. Have you already taken BSN 422? *This question is required.

19. Check courses you have successfully completed or are currently enrolled in. *This question is required.

BSN 346
BSN 381
BSN 380 or 382

Preceptor and Site

Students are expected to find a preceptor and site for BSN 423 clinical.

Here is a list of some of our contracted sites: BSN 423 Contracted Clinical Sites (scroll to bottom of webpage)
Instructions for requesting a preceptor can be found in the BSN Clinical Handbook .

20.

Preceptor Information

Preceptor First Name

Preceptor Last Name

Preceptor Title

Preceptor Email Address

Preceptor Phone Number

21. Site information

Site Name

Site Address

Apt/Suite/Office

City

State

Zip

County

Email Address This question requires a valid email address.

Phone Number

URL (if applicable)

22. Please sign below confirming you have reviewed the BSN Clinical Handbook
> Please be aware that Covid waivers are not accepted at our clinical partner sites, at this time.
*This question is required.

Clear

Signature of

BSN 423 Fall Clinical Application - March 1 - May 1

Preceptor Information