/ UVic School of Nursing
Post RN Diploma BSN Students
Registered Practicing Nurses Studying for a Nursing Degree
Practicum/Stage Request

Practicum/Stage request for third and fourth year BSN students in NURS 351, 431 and 495:

  • UVic submission dates are set to meet the request deadlines of health authorities/organizations
  • Type your information in this fillable form (no hand-written submissions accepted)
  • For your request to be processed, submit your request to by the deadline below:

September term by May 1st

January term by Sept 30th

May term by Jan 31st

STUDENT INFORMATION
First Name:Click or tap here to enter text. / Last Name:Click or tap here to enter text. / Any other names used:Click or tap here to enter text.
Student Number: V00Click or tap here to enter text. / UVic Email:Click or tap here to enter text.
(Must use this email for practicums) / Home Phone: Click or tap here to enter text. / Cell Phone:Click or tap here to enter text.
COURSE PLANNING INFORMATION
Practice Course: Select Course / What term and year are you requesting the practicum for: Select Term/Year

WHERE YOU WORK CURRENTLY
Full Name of Health Authority or Corporate Organization:Click or tap here to enter text.
Full Name of Hospital/Agency: Click or tap here to enter text. / Building: Click or tap here to enter text. / Program of Service: Click or tap here to enter text.
Name of Unit: Click or tap here to enter text. / Floor/Room Number (as applicable): Click or tap here to enter text.
Full Address: Click or tap here to enter text.
Website link: Click or tap here to enter text.
Supervisor/Manager/Head Nurse where you work:
Full Name: Click or tap here to enter text. / Email: Click or tap here to enter text. / Phone # & Ext: Click or tap here to enter text.
Do you work: Full Time ☐ Part Time ☐ Casual/Relief ☐
Any other work? Click or tap here to enter text.
FIRST CHOICE PRACTICUM/STAGE REQUEST
Full Name of Health Authority or Corporate Organization:Click or tap here to enter text.
Full Name of Hospital/Agency: Click or tap here to enter text. / Building Name: Click or tap here to enter text.
Program/Service Name: Click or tap here to enter text.
Name of Unit: Click or tap here to enter text. / Floor/Room Number (as applicable): Click or tap here to enter text.
Full Address: Click or tap here to enter text.
Website: Click or tap here to enter text.
SECOND CHOICE PRACTICUM/STAGE REQUEST
Full Name of Health Authority or Corporate Organization: Click or tap here to enter text.
Full Name of Hospital/Agency: Click or tap here to enter text. / Building Name: Click or tap here to enter text.
Program/Service Name: Click or tap here to enter text.
Name of Unit: Click or tap here to enter text. / Floor/Room Number (as applicable): Click or tap here to enter text.
Full Address: Click or tap here to enter text.
Website: Click or tap here to enter text.
STATEMENT OF INTENT FOR PRACTICUM/STAGE REQUEST
To a maximum of 500 words, briefly describe:
  • Your nursing/career interests in this practicum where you will actively participate in the work of the agency/unit/service.
  • How your professional nursing interests align with the course concepts and requirements (see course outlines).
  • What other nursing and relevant experiences (nursing courses or certifications, professional leadership roles, health-focused volunteer experiences) will contribute to your learning and the agency mission in this practicum.
    • Click or tap here to enter text.

The Health Sciences Placement Network (HSPnet), which is used to submit student placement/stage requests to agencies across Canada, require students to use their school issued email address for all communications. Placement/stage requests, confirmations and notifications will be made on your behalf by the UVic School of Nursing with the appropriate contacts responsible for Student Requests in the Professional Practice Departments.
The information on this form will be shared with the agency where a practicum/stage is requested and your course instructor. The collection of personal information on this form is in accordance with section 26 of the Freedom of Information and Protection of Privacy Act and the University Act.