If you would like to download the form and send it to the Pee Dee AHEC, please click on the link below. If you would like to continue to use the online version of the form, simply fill out the information below.

Click here to download file

HPS Placement Form

Fill the form out completely. Uncompleted forms will be discarded. To move the form, click and hold on the word move in the top right hand corner and drag it where desired.

Fields marked with a * are required.

 

* Your Name:

* Your Email:

* Your Rotation Course Number (ex. MED 486; NURS 471):

* Your Discipline:

Please select a grouping:

Chiropractic
Clinical Laboratory Sciences
Clinical Psychology
Community Health Worker
Dental Assistants
Dental Public Health
Dentistry
Food and Nutrition Services
Health Administration
Health Information
Medicine, Allopathic
Medicine, Osteopathic
Medicine, Preventive
Mental Health
Nurse, Anesthetist
Nurse, Midwife
Nurse, Practitioner
Nursing, Undergraduate
Pharmacy
Physician Assistant
Public Health
Rehabilitation
Social Work
Technicians and Technologists
Veterinarian
Other Advanced Practice Nurse
Other Allied Health
Other

* Start Date:

* End Date:

* Clinical Site:

* Clinical Site Address:

* Academic Program (ex. MUSC Health Administration, MUSC Nursing, MUSC PA, etc):

* Year in Program:

* Expected Graduation Date:

Your Marital Status:

Single
Married