Appendix N: Clinical Make Up Petition Form
Moberly Area Community College
Nursing Student Clinical Make-Up Petition Form
Student Section: This petition must be submitted within one week of the missed clinical date. STUDENTS MUST MAKE UP ALL CLINICAL HOURS IN ORDER TO MEET CREDIT HOUR REQUIREMENTS. A DETERMINATION THAT THE STUDENT MAY NOT MAKE UP THE CLINICAL DAY FOR A GRADE DOES NOT EXCUSE THE STUDENT FROM COMPLETING THE REQUIRED CLINICAL HOURS THAT WERE MISSED. THE STUDENT MUST MAKE ARRANGEMENTS WITH THEIR INSTRUCTOR TO MAKE UP THE CLINICAL HOURS EVEN IF THEY WILL NOT RECEIVE A GRADE FOR THE EXPERIENCE.
I, _____________________________________________, wish to petition the nursing faculty of Moberly Area Community College to schedule a make-up clinical day for the following clinical experience, ___________________________________________ originally scheduled on (date of absence)_____________.
I am in the __ Practical Nursing __ Associate Degree Nursing __ LPN to RN Bridge Program (check one).
My expected date of graduation is ____________________________.
I was absent/tardy due to the reason(s) outlined below, and supporting evidence accompanies this petition.
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Faculty Section: Instructors submit a copy to the Director of Nursing and to the student, and place a copy in the student’s file.
We, the faculty, after careful consideration, have determined the student:
_____MAY make up the clinical day FOR A GRADE.
*** Instructors may need to provide alternate clinical experiences due to limited clinical site availability. Arrangements for make-up days and/or alternate assignments should be communicated clearly (in writing) to the student.
_____May NOT make up the clinical day FOR A GRADE and will receive a zero for the day (paperwork and performance).
Faculty Signatures:
Director of Nursing: __________________________________________________
PN Coordinator: _____________________________________________________
ADN Coordinator: ____________________________________________________
Student Signature: ______________________________ Date: ______________