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Guidelines for Form Completion

Please follow the information below to ensure correct and timely completion of the two (2) different PICS forms:
PICS project approval form 
PICS hours submission form (pdf)

PICS project approval form

All service activities must have prior approval via the PICS project approval form.

Requestor Information

  • Name
  • e-mail address
  • Class (P1, P2, P3)

Project Information

  • Title
  • Date and time
  • Location
  • Contact person (for health-related patient care activities, this person must be a healthcare professional or a faculty person)
  • Description (this should be a brief description of the activity explaining what the activity will entail)

PICS hours submission form

This form must be submitted within thirty (30) days of the completion of the activity

Commonly missed or incorrectly completed portions of the PICS hours submission form.

  •  Supervisor’s Name and Telephone Number
    • For health-related patient care activities, this person must be a healthcare professional or a faculty person.
  • Brief Description of Service Activity
    • This should be very brief
    • Examples:
      • blood pressure and glucose checks
      • coached a little league team
  •  Number of Service Encounters
    • This should be a numeral (e.g. 25)
    • This is required for all categories of PICS hours
    • Your form will be returned if it is not filled out correctly