NRS 425 T4 Community Teaching Project Interview Acknowledgment Form

Student Name:

Course Section and Faculty Name:

Date of Interview:

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