Internship/Rotation - Community Health Center Association of Connecticut (CHCACT)

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HEALTH PROFESSIONS STUDENT PLACEMENT/CLINICAL ROTATION/INTERNSHIP REQUEST FORM

Thank you for your interest in obtaining clinical placement at one of CT's FQHCs. We will do our best to honor your request, however, all specialty areas are not offered at all locations. The form below must be filled out completely and submitted with a copy of your CV. CHCACT will review your request and forward to the appropriate FQHCs and they will be in touch with you directly. If you have any questions regarding this form, please contact Dionne Kotey.

Date
Date Format: MM slash DD slash YYYY
Name*
First Last
Email*
Phone*
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
School/University*
School/University Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
AAMC# (If Applicable)
Degree Program*
Current Year in Program*
Name of Contact at Program*
Contact Person Phone Number*
Specialty Area Requested for Rotation*
Rotation Begin & End Date*
Number of Rotation Hours Needed*
Citizenship*
Preferred Health Center Location(s) in CT*
- Fairfield County
- Hartford County
- Litchfield County
- Middlesex County
- New Haven County
- New London County
- Tolland County
- Windham County
Have you had a previous health center rotation*
Have you completed HIPAA and Universal Precautions training?*
If you answered Yes to the above question, please indicate date completed
Please upload a copy of your CV here*
Additional Questions/Comments
Name
This field is for validation purposes and should be left unchanged.

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