STUDENT VERIFICATION FORM: - PDF document

STUDENT VERIFICATION FORM: All students who will be doing clinicals at Cleveland Clinic Health System are required to complete an application. Please cplete all the information and write . Once the completed paperwork is received in the APN Office the application is entered into Red Carpet to launch an onboarding event or processing of a student identification number. �� Page of Academic Institution: ______________________________ Phone Number: ( ) - - IF YOU HAVE PREVIOUS STUDENT BADGE PROVIDE NUMBER____________________________ Academic Program: ____________________________ Academic Program Director: ______________ __ _____ _______________ ___ Clinical Rotation Start Date: / / Clinical Rotation End Date: / / Completing this form verifies that the following studentsand clinicalfacultyhave completed the necessary requirements as outlined in the Academic Institution’s Clinical Education Agreement with the Cleveland Clinic (the “Agreement”). (See page 2 for instructions.) The students and academic clinical faculty identified below will be at which of the following Cleveland Clinic Health System facilities? Euclid Fairview Hillcrest Huron Lakewood Lutheran Main Campus Marymount South Pointe Medina Other Student NameMUST PRINT INFORMATION linical Program ( e.g. Adult, Family) Social Security Number (must be all 9 digits) Students Date of BirthMonth/Date/Year Phone Number Anticipated Dateof Graduation Name: Cleveland Clinic Employee Yes No Clinical Hours Required:Email: (PLEASE COMPLETE LEGIBLY) Preceptor Name/Names: Has the student performed clinicals at Cleveland Clinic Previously: Yes No MUST BE COMPLETED: Health Requirement Met Yes: CPR Requirement Met Yes: Negative Background Check Confirmed: Yes Current RN L icense Confirmed: Yes Malpractice Insurance Confirmed: Yes Influenza Vaccination Yes Date & Location: ________ As stated in the Agreement, documents verifying compliance with the above requirements must be made available to the Cleveland Clinic within 24 hours of request. Please identify the person wshould be contacted in the event that the Cleveland Clinic needs to request documentation. Please note this must be either signed by Program Coordinator at the College or the Clinical Faculty. Signature of Clinical Instructor OR Program Coordinator: _________________________________________________ Title: ________________________________________________________ Phone Number: ( ) - - Email Address: ________________________________________________________ Please FAX or email the completed and signed Verification Form Waiver and Confidentiality Statement for ms : Program Coordinator: AX: (216)Email Address: mcdonom@ccf.org APN OFFICE USE ONLY Faxed to HR:Information to Student:Student Number:�� Page of 11.23.2011 Instructions:It is imperative that all of the information is legible and accurate. Please double check the correct spelling of the student and onsite academic clinical faculty names, dates and numbers. The request for information is consistent with the clinical affiliation agreement between the Cleveland Clinic and the Academic Institution. Academic Institution:Full name of the academicinstitution Academic Program:Full name of the academicprogram Academic Program Director:Full name of the academicprogramdirectorresponsible for communicating with the Cleveland Clinic . Phone Number:PhoneNumberof the academicprogradirector Email Address:EmailAddressof the academicprogramdirector Clinical Rotation Start Date:The datestudents identified below begintheir clinical rotation at the Cleveland Clinic facility. Clinical Rotation End Date:The datestudents identified below their clinical rotation at the Cleveland Clinic facility. Cleveland Clinic facility:Mark the box with an “X” next to the Cleveland Clinic facilitywhere students(s) will be training. Name:Identify the Nameof the student and onsite clinical faculty that will be at the Cleveland Clinical facility for the clinical rotation. Email:Identify the student and onsite academic clinical faculty EmailAddress Date of Birth:Identify the student and onsite academic clinical faculty datebirth(NOTE: Students must be 18 years of age at the time they begin their clinical rotation.) Social Security Number:Identify the student and onsite academic clinical faculty SocialSecurityNumber Phone Number:Identify the student and onsite academic clinical faculty phonenumber Anticipated Date of Graduation:Identify the expected datethe student will completetheir academic program. Health Requirements:When this box is marked with an “X” it means that the student and onsite academic clinical faculty have metallhealthrequirementsidentified in the Agreement, i.e., a negativetwostepMantouxor QuantiFERON® TB Gold test (TB test) within yearbeforethe started date of the clinical rotation with annualupdateswhile in the clinical portion of their training, appropriate immunizations for measles (Rubeola), German measles (Rubella), chicken pox (Varicella), DT Diphtheria/Tetanus booster within the last 10 years, proof of Hepatitisimmunization/immunity or signed waiver assuming the risk of exposure; and compliance with any future tests required by the Cleveland Clinic. CPR Requirement:Student and onsite academic clinical faculty must have current AmericanHeartAssociationHealthcareProviderBasicLifeSupportCPR course certification, if required by the specific program. Negative Background Check:The academic institution must verify that each student and onsite academic clinical faculty has a negativebackgroundcheckfingerprint methodonly Signature:Signatureof the academic dean or his/her designee responsible for verifying the accuracy of the information on this form. Name:Nameof the academic dean or his/her designee responsible for verifying the accuracy of the information on this form. Title:Titleof the academic dean or his/her designee responsible for verifying the accuracy of the information on this form. Email Address:EmailAddressof the academic dean or his/her designee responsible for verifying the accuracy of the information on this form. Phone:PhoneNumberof the academic dean or his/her designee responsible for verifying the accuracy of the information on this form. Date:Datethesignature NOTE:According to the Agreement, the School agrees to require students to have health insurance providing basic medical, surgical and hospitalization benefits, and professional liability and malpractice insurance with limits of one million dollars ($1,000,000) per occurrence and three million ($3,000,000) aggregate for students and onsite academic faculty. The Cleveland Clinic Program Director may require students to provide a copy of these documents for reference.�� Page of 11.23.2011