Service Learning Form

Service Learning Form

Please fill out the following information regarding your service learning experience.
Student Name

First NameLast Name
First Name
Last Name
Student Email Address
Current Semester Enrolled
Date of Completed Service

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name and Address where service was provided
Supervisor Name
Hours Served
QSEN (Quality and Safety Education for Nurses) outlines the core areas every nurse must practice to provide safe, high-quality care. It focuses on six main ideas: putting patients first, working well with the healthcare team, using current evidence to guide care, improving systems when problems are identified, preventing harm, and using technology correctly. As a new nursing student, QSEN simply means learning how to care for patients safely, thoughtfully, and as part of a professional team.

Please refer to UNC's QSEN alignment below:

UNC Program and Student Learning Outcomes
Choose the QSEN domain that your service learning is most relevant for.
Choose the content area that your service learning is most relevant for.
Provide a detailed rationale for how your service learning meets your chosen QSEN domain and content area.
Upload your completed and signed Service Learning Document

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