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Campus Information:

Externship Coordinator:   Phone Number:  

Student Name:   Phone Number:  

Placement Information:

Facility/Office of Placement:  

Doctor/Contact Person:  

Address/City:  

Facility Phone #:   Hours of Operation:  

Start Date: Start Time:  

Orientation/Interview Required: YesNo Date/Time:

Student Accepted Externship: YesNo 

If Rejected: Student must give reason why and their plan for completing externship:

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Document name: Student Externship Placement

Unique Document ID: 678badfc868a45e05e0d724585264b9425673c3a

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Timestamp	Audit
April 29, 2022 9:15 AM EDT	Student Externship Placement Uploaded by MedCertify Education - [email protected] IP 99.190.9.234
April 29, 2022 9:44 AM EDT	MedCertify Edu - [email protected] added by MedCertify Education - [email protected] as a CC'd Recipient Ip: 99.190.9.234
May 2, 2023 1:21 PM EDT	MedCertify Edu - [email protected] added by MedCertify Education - [email protected] as a CC'd Recipient Ip: 99.190.9.234

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Audit Trail Serial# 67f1d6cf6944b0c134739a1282a3b0c0