FALL_09_Revised_Semester_8_Clinical_Forms1 - Name ID Number...

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Unformatted text preview: Name ID Number 1 C HECK L IST FOR S EMESTER 8 C LINICAL F ORMS C OPIES – C OMPLETE ALL OF THESE FORMS , THEN MAKE A COPY FOR YOUR RECORDS T URN IN ALL P AGES BY F EB . 28 (B RING TO HB 420) U SE YOUR COMPUTER , TYPE , OR NEATLY PRINT YOUR RESPONSES . T HE FORM MUST BE READABLE IN ORDER FOR US TO WORK WITH IT . Please make sure that you save your work on your computer O R print out what you have completed These forms W ILL N OT automatically save when you navigate away from this page. PAGE 1 – CHECK LIST FOR SEMESTER 8 CLINICAL PAGE 2 – STUDENT INFORMATION AND CLINICAL PREFERENCE PAGE 3 – QUALIFICATIONS FOR PLACEMENT PAGE 4A – PREVIOUS CLINICAL PLACEMENTS PAGE 4B – SPECIAL NEEDS PAGE 5 – CLINICAL DOCUMENTATION FORM + COPIES OF YOUR: #1 – Personal Health Insurance Card or ID #2 – CPR Card #3 – PPD – TB or Tuberculin Test #4 – Titers and results for Varicella, Measles, Mumps, and Rubella #5 – Titer and results for Hepatitis B #6 – DPT or TDAP – Diptheria/Tetanus #7 – Influenza (Flu) Vaccine #8 – Polio (copy needed if you were born outside of the United States) [#9 – Background Check ( no attachments; see p. 5 )] [#10 – Drug Screening ( no attachments; see p. 5 )] #11 – Completed Health Statement – completed by your doctor (copy) BRIDGE RN – Attach copy of your California RN License (make sure that the copy is legible by setting the copy machine to a lighter setting) Name ID Number 2 I NPUT F ORM First Last Name Street Address City Zip Code Address Primary Phone Number – This should be the best phone number to contact you Alternate Phone Number – In case we cannot reach you at the primary number E-mail Address Home Home Cell Cell Work Work Rank your preferences for clinical placement below (Rank 1 – 4 only; 1 being your TOP choice) # Clinical Placements # L Limited Number of Placements L General Medical Unit Psychiatry Medical/Oncology Unit Transitional Care Unit (TCU) Post-Op Surgical Unit Intensive Care Unit (ICU) Ambulatory Unit (same day surgery) Burn Unit Post Anesthesia Care Unit (PACU) Cardiac/Coronary Care Unit (CCU) Rehabilitation/Spinal Cord Emergency Department (ER) Neonatal Intensive Care Unit (NICU) Pediatric Intensive Care Unit (PICU) Labor and Delivery (L&D) Postpartum Acute Pediatrics DO NOT PREARRANGE OR SET UP YOUR OWN PRECEPTORSHIP OR CALL ANY HOSPITAL UNIT ; I F YOU DO , YOU WILL RECEIVE AN "U NSATISFACTORY...
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This note was uploaded on 09/08/2010 for the course NURS 148 at San Jose State.

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FALL_09_Revised_Semester_8_Clinical_Forms1 - Name ID Number...

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