Student Placement Form
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date Picker Icon
Gender
*
Date of Birth (MM/DD/YY)
*
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Student's School Email
example@example.com
1. Do you have a Professional License number?
*
Yes
No
If yes, please type "attached" and provide a copy of Professional License
2. Have you been placed at ZSFG as a student before?
*
Yes
No
If yes, please indicate the Date and Department
Education
Only include applicable degree for student placement experience
School Name
*
School Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Area of Study/Practice
*
Type of Degree
*
1. Approved School
*
Yes
No
2. Approved Program
*
Yes
No
3. Start Date
*
-
Month
-
Day
Year
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End Date
*
-
Month
-
Day
Year
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4. Evaluation for Student Required:
*
Yes
No
5. Hours/Time Required:
*
Yes
No
If yes, what is the requirement (hrs./wks)
6. Course Title:
*
7. Total # of Credits/Units:
School Agents's/Contacts Information
8.School Contact Name:
*
First Name
Last Name
Title:
*
School Contact Email:
*
Phone Number:
*
-
Area Code
Phone Number
9. Course Objectives attached
*
Yes
No
n/a
10. Student contract attached
*
Yes
No
n/a
Precepting Department/Unit
1. Department/Unit
*
2. Student Schedule/Shift
*
3.Department specific Students Responsibilities
*
4. Preceptor Name
*
5. Preceptor E-mail (example@example.com)
*
6. Preceptor Phone Number
*
7. Preceptor Signature
Health Requirements
Students are required to provide proof of immunizations, screening and/or titers of below BEFORE starting placement. Although not required, we strongly recommend Hepatitis B screening and vaccination. For clinical students, health screening is required at the beginning of every clinical rotation. Complete below and show proof to the preceptor/ZSFG STAFF. Actual records are not needed; do not attach.
Provide Date(s) for the following:
*Contact Department of Education & Training (DET) to see if it is an active flu season. Typically the flu season is from Fall through Winter.
Rubella (German Measules): Vaccinated or Titers showing Immunity
*
Vaccinated or Titers showing Immunity
Rubeola (Measules): Vaccinated or Titers showing Immunity
*
Vaccinated or Titers showing Immunity
Varicella: Vaccinated or Titers showing Immunity
*
Vaccinated or Titers showing Immunity
Mumps Vaccinated or Titers showing Immunity
*
Vaccinated or Titers showing Immunity
Seasonal Flu (Flu season only)
*
Flu season only
Tuberculosis: PPD negative/chest x-ray negative (within 1 yr. & 3 months of projected start date, two tests total)
*
PPD negative/chest x-ray negative (within 1 yr.& 3 months of projected start date, two tests total)
Emergency Contact
Please provide a contact person in case of an emergency while on the ZSFG campus or affiliated campus
Name
*
First Name
Last Name
Relationship
*
Phone Number 1
*
Phone Number 2
Health Data Access
In addition to completing below, the preceptor must complete the Invision/LCR Request form and the student must complete the Online User Confidentiality and Security Agreement (forms available on the DPH intranet)
1. Health data access needed
*
Yes (If yes, continue below)
No (If no, proceed to next section)
2. Reason for request
*
3. By checking off the box(s) below you are confirming that you have read and understood each of the applicable policy
*
I understand and agree that it is my legal and ethical responsibility to maintain the confidentiality of all patient medical records and the patient information they contain.
I understand that ZSFG conducts random routine audits of who gains access to medical record without a direct need to know.
I understand and agree that the records must not be removed from the Health Information Systems Department for any reason.
I have received and reviewed the Health Insurance Portability and Accountability Act (HIPAA)
Oath of Confidentiality
As a condition of clinical placement, conducting research, a student internship or the observation of patient care at Zuckerberg San Francisco Hospital and Trauma Center, I agree not to divulge any information obtained in the course of such training or research to unauthorized persons, and not to public or otherwise make public any information regarding persons who have received resources such that the person who received services is identifiable. I further agree not to divulge or public general patient information or statistics without prior authorization from my preceptor or hospital administration. I further agree to hold in strict confidentiality on all matters discussed on Medical Staff or hospital committee meetings to which I might be privy. I recognize that the unauthorized release of confidential information may make me subject to civil action under provisions of the Welfare and Institutions Codes.
Signature
*
Date
*
-
Month
-
Day
Year
Date Picker Icon
Orientation
I attest that the above named student has been orientated to the hospital by completing online based orientation via Litmos Learning Management System. He/she has been introduced to Department/Unit/Clinic specific standards and protocols.
Preceptor Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date Picker Icon
Dept/Unit
*
Preceptor Signature
Student Declaration
I certify that the information provided on this form is true, accurate and complete. I agree to provide the immunization/screening records upon the hospital’s request. I understand that any false information will cause my disqualification in any programs on the Zuckerberg San Francisco General Hospital (ZSFG) campus and affiliated clinics. I recognize that all confidential information obtained or observed at ZSFG is in confidential nature. I agree, that at all times, to ensure the confidentially of all sensitive information I have contact with, comply with applicable laws and maintain patient privacy. I understand that failure to comply with any of the above requirements may result in cancellation of my instruction agreement. I further attest that I have received appropriate written material and introduced to the hospital and the appropriate department/unit/clinic protocol and standards.
Date
*
-
Month
-
Day
Year
Date Picker Icon
Signature
*
Clear
Submission
Please click the Print Button below and submit this form directly to your assigned preceptor (ZSFG staff contact or department). If you have any questions regarding this form, contact your preceptor (preferred) or Department of Education and Training at 628.206.4655
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