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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

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