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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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