Nursing Instructor Credentialing

Name

First NameMiddle InitialLast Name

School Email

example@example.com

Credentials

Cell Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Date of Birth

What program are you an instructor for?

Examples: BSN, ADN, etc.

What school are you affiliated with?

If you selected 'other', please enter your school affiliation:

Area of rotation (select all that apply):

If you selected 'med surg', please specify:

Other

Would You like to purchase a UK badge?

$25 for a badge with door access, $5 for no door access

If yes, would you like door access for $25? If no, the cost will be $5.

You will be sent an invoice for payment through email!

If so please upload a photo:

The following documentation is required for all Instructors and Learners rotating at UK St. Claire.

A Letter from the institution stating that the student/resident is in good standing

Letter must be addressed to Sue Russell, Student Services Coordinator, typed on letterhead, include name, academic year dates and signed by the one administering the letter
- Criminal/Caregiver background check that shows the student does not have any past history of drug abuse, felony, etc
- Drug screen results showing a negative
- Immunization and health records showing 2 MMR’s or titers drawn showing immunity, compliant with CDC recommendations
- Results from a two-step TB Skin Test is required and consistent with CDC guidelines for SCR. These are 2 separate tests with the second test administered within the last year of rotation start date and the first test administered within the last year of the second one. This type of testing is compliant with CDC recommendations for SCR. If you have never had a TB skin tests done, please allow at least a 2 week time frame for both tests to be administered before you start your rotation.
- Annual flu shot has been administered during the flu season time frame of October 1 – March 31. (Must provide a copy for UK St. Claire)

By checking this box, you confirm that your institution will submit the required documentation on your behalf through the Letter of Good Standing or that you work at UK St. Claire HealthCare:

Please upload proof of annual flu shot:

Signature

Today's date:

Date