HODGES UNIVERSITY DEPARTMENT OF DENTAL HYGIENE
STUDENT CLINICAL REMEDIATION FORM
Student Name: ______________________________Date: ______________ SKILL: _____________________________ Assignment:
________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
__________________________ __________ __________________________ __________ Student Signature Date Instructor Signature Date
One-on-One Session Date: _______________Time Started: __________________Time ended: ___________
Specific Comments and Recommendations Relating to this Course: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
__________________________ __________ __________________________ __________ Student Signature Date Instructor Signature Date
Independent Practice Documentation Date: __________ Time Started: __________ Time Ended: __________ Date: __________ Time Started: __________ Time Ended: __________
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Dental Hygiene Program
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