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  6. Student Intake Form

Student Intake Form for AHN Clinical Rotation

Thank you for your interest in completing a clinical rotation with AHN. This form is for students seeking a rotation that is an educational requirement. Please complete the following form in its entirety to move through the student onboarding process.

This form is not for medical students, shadowing experiences or undergraduate nursing students – for those programs please visit www.ahn.org for more info.

At AHN, the student onboarding process begins with submission of the student intake form, not within myclinicalexchange.com. If you’ve already entered info into myclinicalexchange.com, the request will be denied and you will be directed to submit your intake form.

Timing: Rotations are reviewed 60 to 90 days in advance. If you are requesting a rotation beyond 90 days in advance, your rotation request will not be processed. Please wait to submit this form within the appropriate timeframe.

Student Intake Form

Your information
Additional information

Have you gone by any other names in the past?

Not quite. Try again.
  • Yes
  • No

Any other email addresses you may utilize in communications or have used to complete a rotation with AHN before.

About clinical rotation

Please provide the specialty you need for this rotation

Processing of rotations requires a minimum of 3 weeks prior to your rotation start date. Rotations are reviewed as early as 90 days in advance. If you are submitting for a rotation beyond 90 days in advance, please wait to submit this form.

End date of rotation

Have you completed a clinical rotation with Allegheny Health Network before?

Not quite. Try again.
  • Yes
  • No

If you are a current AHN employee, please provide your employee ID # (This includes contract workers that are paid by AHN.  Answer N/A if you are not currently employed by AHN).

In the field below, list your preceptor's name and e-mail address

Please Note: AHN Health Sciences does not place students for clinical rotations. Please work with your school to identify AHN preceptors for the rotations needed. Only submit the student intake form once you have an approved rotation with an AHN preceptor.

Please provide the location of the rotation being requested

About your school

What program (degree) are you currently studying that requires this rotation?

Is your school’s coordinator aware you are requesting this rotation?

Not quite. Try again.
  • Yes
  • No

School coordinator name and email