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  • CLINICAL FACILITIES FORM

    Walden University
  • PLEASE NOTE: This form is for Walden University students only. You must be approved in order to obtain the authorization code. 

  • INSTRUCTIONS: All requirements must be met and all required attachments downloaded, to successfully submit this form. Be sure to have the following completed and available prior to completing this form:

    • Confidentiality Agreement
    • Computer Access/ISS Form 
    • HIPPA Certification
    • Proof of Immunizations
    • Proof of Physical Examination
    • Proof of Fit Testing
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  • CLINICAL FACILITIES FORM

    Walden University
  •  STUDENT SECTION
  • A. Student Name
     

    To complete the below, enter the first and last name of the student and you MUST click the "Click To Add Student" button or entries will not be saved. 
  • B. Requirements


    UCLA has very specific requirements for immunizations in order to be placed in the units. You must provide proof of immunization documentation, proof of fit testing (within the last 12 months), and proof of physical evaluation (within the last 12 months) to UCLA Health. These requirements will be required to attach on page 4 of this submission. 

    ** When rotating at UCLA Hospitals, it is your responsibility to ensure that you are tested for and free of active tuberculosis. To meet this requirement, a Quantiferon Gold, T-Spot or “2 Step” Tuberculin Skin Test must be completed within 3 months of UCLA student placement assignment.  Students with assignments that exceed 12 months must be TB tested annually and be free of active tuberculosis at all times.

    By checking the below requirements, you attest that all of the areas are completed and up to date.

  • C. Competencies (all are required)
     

     
  •  **By checking this/these options, you verify this/these options will be completed and kept on file within the first week of being on the unit.
  • Competency Links to complete

    Self-Study Orientation Guide and Staff Information Handbook

    HIPAA Education and Training

    Nursing Department Specific Orientation 

    Life and Safety Checklist - Students


  • CLINICAL FACILITIES FORM

    Walden University
  •  ATTACHMENTS
  • Form Links:

    HIPAA Education and Training

    Confidentiality Agreement

    ISS Computer Access Form 

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  • CLINICAL FACILITIES FORM

    Walden University
  • Submission of this form does not guarantee placement. Once all paperwork is complete, you will receive an email indicating if you have been cleared.

    I attest that the above information is correct and that I am responsible for keeing my own records and providing to UCLA if requested: 

  • Clear
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