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)

Required Immunizations (all are required for Oregon)

Rows	Yes
Hepatitis B (Hep B)
Measles, Mumps and Rubella (MMR)
Tetanus, Diphtheria, Pertussis (Tdap)
Varicella
Covid-19

Immunizations:

Rows	Yes	No
Polio
Influenza

Required Screenings (all are required in Oregon)

Rows	Yes
Tuberculosis (TB)
Social Security Number Trace
National Criminal Background Check
OIG LEIE Check
OIG EPLS Check
Sex Offender Registry Check
Substance Abuse - 10-Panel Drug Screen

Required Training

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

Insurance and Liability Coverage (all are required in Oregon)

Rows	Yes
Professional Liability Insurance
General Liability Insurance

Insurance and Liability Coverage

Rows	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.