Infinity Rehab Student Requirement Form

Schools must provide written evidence of ALL of the following PRIOR to beginning any student clinical placement

First Name*

Middle Name*

Last Name*

Name*

First NameMiddle NameLast Name

Student Name

Student Date of Birth

MonthDayYear

Student Email

Student Phone Number

Site of Upcoming Clinical Experience

Dates of Upcoming Clinical Expeience

Number of Previous Clinical Rotations

Anticipated Graduation Date (Month/Year)

Immunizations (recommended but not required)

	Yes	No
Measles, Mumps and Rubella (MMR)
Tetanus, Diphtheria, Pertussis (Tdap)
Varicella
Polio
Influenza

Required Immunizations *

	Yes
Hepatitis B (Hep B)
Covid-19

Screenings (required)*

	Yes
Tuberculosis (TB)
Social Security Number Trace
Criminal Background Check in State of Rotation
National Criminal Background Check
OIG LEIE Check
OIG EPLS Check

Training (required)*

	Yes
Health Insurance Portability and Accountability Act (HIPAA)
Bloodborne Pathogen Training (OSHA)
CPR/Basic Life Support (BLS) for Healthcare Providers

Insurance and Liability Coverage (required)*

	Yes
Professional Liability Insurance
General Liability Insurance

Insurance and Liability Coverage

	Yes	No
Current Student Health Insurance (or coverage via Workers' Compensation Insurance extended to students by school) (recommended but not required)

To be SIGNED by school representative completing form:

I attest that the above information is accurate, and affirm that the school will release proof of compliance for any item above to Infinity Rehab upon request.

Name:

Title:

College & Program:

Date:

MonthDayYear

Please submit this completed checklist at least 30 DAYS PRIOR to the upcoming rotation to Infinity Rehab.