Student Clinical/Practicum Hour Request

The Gallia County Health Department makes every effort to accommodate students at all levels and specialties. To ensure our staff are able to place each student with the appropriate GCHD staff member, please complete this form in its entirety. Once completed, a GCHD staff member will be in contact with you to discuss logistics. Please note that while all efforts are made to accommodate all students requesting hours with the GCHD, availability and staffing may limit us from accommodating all student requests. Should you have any questions (regardless of specialty), please reach out to Melissa Conkle (Director of Nursing) at 740-441-2960.

1. Full Name: *This question is required.

2. Phone Number: *This question is required.

3. Student's Address: *This question is required.

4. School Attending: *This question is required.

5. Degree Working Towards: *This question is required.

6. Specific Class/Clinical Needed (ex: Environmental Health, Community/Public Health, Nursing General, etc.): *This question is required.

7. Number of Hours Needed: *This question is required.

8. Month Clinicals Need to Start: *This question is required.

9. Potential Number of Hours Per Week at the GCHD: *This question is required.

10. Additional information the GCHD needs to know regarding your experience: *This question is required.