Health Promotion – Topic 4

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:

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

© 2023. Grand Canyon University. All Rights Reserved.

Anai Borrego Rodriguez

Anai Borrego Rodriguez