Jr Hospital Of Cook County - University Of Illinois Page 2
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4John H. Stroger, Jr. Hospital of Cook County
Cook County Health & Hospital System
(formerly Cook County Bureau of Health Services)
Name:
Address:
Phone:
E-Mail Address:
School:
Address:
Phone:
Supervisor:
E-Mail Address:
Indicate your objectives for this experience. What are you expected to do (observe, participate in patient care, interview
employees, etc)?
SENDING INSTITUTION’S APPROVAL:
JSH APPROVAL:
The requested clinical experience is related to and is a required part
of the student’s educational program. Basic preparation for this
experience has been provided the student through classroom
instruction and laboratory practice.
Department Head
Date
Approved
Denied
Signature of Dean/Department Head
Date
Chair, Department of PER
Date
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