NRS-425 COMMUNITY TEACHING PROJECT – INTERVIEW ACKNOWLEDGMENT FORM

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NRS-425 Community Teaching Project – Interview Acknowledgment Form

NRS-425 Community Teaching Project – Interview Acknowledgment Form
NRS-425 Community Teaching Project – Interview Acknowledgment Form
Students must submit this form in the digital classroom in Topic 4.
Student Name:
Course Section and Faculty Name:
Date of Interview:
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Representative Information
Representative Name :
 
 
 
 
Last
First
M.I.
Credentials:
 
Title:
 
 
(i.e., MS, RN)
Organization:
 
Phone Number:
 
Email Address:
 
D
 
 
 Provider Acknowledgement
I ___________________________ acknowledge that ____________________________
 
(Representative’s Name)
(Student’s Name)
has interviewed me and received feedback about the above-mentioned organization and community for their Community Teaching Project. The organization/agency does not endorse the university or the student; however, the teaching plan developed by the student is considered appropriate and of benefit to the community of interest.
 
 
 
Representative’s Signature (must be handwritten)
 
Date Signed
NRS-425-RS-T4-InterviewAcknowledgmentForm

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