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