Adobe FormsCentral

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.
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
Today's Date *

Month Day Year
Date
School *
Contact Number *

Area Code Phone Number
E-mail *
Hospital Location *
Rotation *
Year *
Unit Location *
Course Title *
Course Syllabus *
Clinical Start Date *

Month Day Year
Date
Clinical End Date *

Month Day Year
Date

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
HIPAA Certificate *
Confidentiality Agreement *
ISS Computer Access Form
NOT REQUIRED FOR UCLA HEALTH EMPLOYEES
Proof of Vaccination Documents *
Proof of Fit Testing *
Proof of Physical Evaluation *

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:
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

CLINICAL FACILITIES FORM

CLINICAL FACILITIES FORM

CLINICAL FACILITIES FORM

CLINICAL FACILITIES FORM