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CLINICAL FACILITIES FORM

UCSD Lactation Program
INSTRUCTIONS: Please note that all requirements must be met and all required attachments downloaded, to successfully submit this form. Be sure to have your completed Confidentiality Agreement (signed by the student[s]), the ISS Computer Access Form (completed by the coordinator), and HIPPA Certification documents ready prior to completing this form.
Today's Date *

Month Day Year
Date
Your Name *
Contact Number *

Area Code Phone Number
E-mail *
Hospital Location *
(select all that apply)
Rotation *
Year *
Unit Location *
Clinical Start Date *

Month Day Year
Date
Clinical End Date *

Month Day Year
Date

CLINICAL FACILITIES FORM

Student Section
A. Student(s) Name
B. Requirements

UCLA has very specific requirements for immunizations in order to be placed in the units. Students must provide all documentation to their school and the school must have these available upon request.

** It is the School's responsibility to ensure that the instructors and students rotating at UCLA Hospitals 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 complete and will be kept on file at your school.
C. Competencies (all are required)
**By checking this/these options, you verify this/these options will be completed and kept on file at your school within the first week of the student 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

UCSD Lactation Program
IMPORTANT: All Clinical Facilitites Forms MUST be completed and signed by the school's contact. Any submissions that are completed by the student will be declined.
Submission of this form does not guarantee placement, as your unit contact will determine the number of students they can accommodate. Once all paperwork is complete, you will receive an email indicating the students who have been cleared.

I attest that the instructor and/or student(s) information is correct and that I am responsible to keep this information on file at the school if requested by UCLA:
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

CLINICAL FACILITIES FORM