Graduate Student Non-Clinical Placement Request

Graduate Student Non-Clinical Placement Request

Do not complete this form if you are requesting a Clinical Graduate Placement
Application Form
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email Address*
Name of Nursing School*
Name Faculty Contact*

First NameLast Name
Faculty Contact Phone Number*

Area CodePhone Number
Faculty Contact Email Address*
Type of placement requested*
Program of Study*
Specific Area of Study*
Area of placement requested*
Indicate placement reason*
Specific Area of Study*
Start Date for Non-Clinical Placement*

MonthDayYear
Date
End Date for Non-Clinical Placement*

MonthDayYear
Date
How many hours are you required to complete*
Are you a Children's National Employee*
Were you a previous Children's National Employee*
Current and previous employees, please provide Employee ID#
Do you need dual access in CERNER for this placement. Please note that you can't document any care you provide as student under your Children's National employee role. If you need to document in the medical record you will need dual access.*
Signature*
Please complete the follow requirements if you are not a Children's National Employee.
I First Name Last Name am not an employee of Children's National Hospital. I have understand that it is my responsibility to protect all private health information. I understand that if it is found at anytime related to my activities that I have inappropriately shared or used the information about patients (written, verbal or photo) of Children's National Hospital that my placement may be terminated.
Signature
Occupational Health Requirements:

Tuberculosis Screening

Each NEW student must have ONE skin test (PPD). After the skin test is administered, the recipient must return within 48 to 72 hours to have the result read and recorded.
The PPD should be completed within 30 days of the start date.
OR
Quantiferon within the past 90 days.
TTB (PPD, Quantiferon or T-Spot) positive volunteer applicants must provide chest x-ray reading result (within 12 months of application).
**Students who continue rotations for more than one year must complete the annual health update form which includes a TB Risk Assessment and Symptom Screen**
Each student must submit documentation of proof of immunity to Chicken Pox, Measles, Mumps & Rubella, Hepatitis B, and provide evidence of Tdap vaccine and updated Flu shot verification - Sept – May

Two acceptable forms of documentation include:
• Immunization records (2 MMR vaccines, 2 Varicella vaccines, 3 Hepatitis B vaccines, Flu vaccine for current flu season, and Tdap vaccine)
• Results of blood work including titers for varicella, measles, mumps and rubella, and hepatitis B

Health Screening Form-Non-Employees
CoVid Requirements:
Completion of a primary series (i.e., 2 monovalent vaccines, 1 J&J, 1 bivalent vaccine, or any WHO approved vaccine)
May use an approved CNH medical exemption).
Monitor symptoms daily and report any concerns to HR.
DC RN License

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Submit evidence of up-to-date Immunization Record

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Submit evidence of Background and Sex Offenders Screening

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Submit evidence of BLS certification

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