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