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:
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.
Competency Links to complete
Self-Study Orientation Guide and Staff Information Handbook
HIPAA Education and Training
Nursing Department Specific Orientation
Life and Safety Checklist
ISS Computer Access Form
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: