AUTHORIZATION FOR ROTATION TO UCDHS

							                                                                                                                           Submit To: Center For Nursing Education
                                                                                                                                    Broadway Building, Suite 1630
                                                                                                                                                        Page 1 of 2


                   AUTHORIZATION FOR SHORT-TERM ROTATION TO UCDHS (NURSING)
                             WHERE NO TRAINING AGREEMENT EXISTS
Name:
(Last)                                                        (First)                                                          (Middle)
Post Graduate Training Level:                                 Social Security No.:

Home Institution:                                                                              Training Specialty:
Medical Service to Which Assigned at UCDHS :

Rotation Start Date:                                                                           Rotation End Date:

Nursing License Number:                                                                        Expiration Date:
CPR Expiration Date:                                                                           Signed Confidentiality Agreement:
TB Skin Test Current (through period of rotation):                                             [agreement kept by Center for Nursing Education (“CNE)]
Rubella Titer or Immunization Date:                                                            Signed Needlestick Form:
HIPPA Training Date:                                                                           (agreement kept by Department)
Training Institution: UC Davis (UCDHS)                                                         Graduation Date (mm/dd/yyyy):
   UCDHS has reviewed the credentials of the Registered Nurse and has accepted her/him for an elective rotation. The privileges to be granted to the Registered Nurse are liisted in
    the Description of Duties, which will be provided to the Registered Nurse and CNE by the Nursing School/Training Institution.
   Home Institution and the Registered Nurse shall assure all documentation requested in Attachment 1 is provided as directed and shall comply with all requirements listed therein,
    as applicable.
   Home Institution warrants no disciplinary actions have been taken or are pending against the Registered Nurse and the Registered Nurse has not been involved in any
    claims, actions or formal complaints related to patient care.
   The Registered Nurse shall perform the duties and responsibilities listed in the Description of Duties. During the rotation, the Registered Nurse shall comply with UCDHS policies
    and procedures.
   Home institution or the Registered Nurse shall provide professional liability coverage applicable during the rotation and shall provide evidence of coverage to UCDHS before the
    rotation begins.
   UCDHS and Home Institution each agree to defend, indemnify and hold each other and each other’s respective officers, agents, and employees, harmless from and against any
    and all claims liability, loss, expense, including reasonable attorneys’ fees, or claims for injury or damages arising out of the performance of the rotation, but only in proportion to
    and to the extent such liability, loss, expense, attorneys’ fees, or claims for injury or damages are caused by or result from the negligent or intentional acts or omissions of the
    indemnifying party, its officers, agents, or employees.
   During the rotation, the Registered Nurse shall be considered neither a student nor employee of UCDHS.
   Upon completion of this rotation, if not a UCDMC employee, the Registered Nurse shall return UCDMC photo-ID badge, University keys, and any other University property loaned
    to the Registered Nurse during the rotation.
APPROVED AND AGREED                                                                            RETURN COPY TO:
                                                                                               __________________________________________
Signature                        Print Name                                                    Kathleen Guiney, R.N., M.S.N
Program Director - Sponsoring Department, UCDHS                                                Nurse Educator, Center for Nursing Education, UCDHS
                                 Date:                                                                                           Date:



Rotating Registered Nurse’s Signature                                                          Signature                       Print Name
Email Address:                                                                                 Training Program Director - Home Institution
                                   Date:                                                                                       Date:


                                                                                               Form completed by:
Annie Wong, Health System Contracts Director
                                Date                                                           Telephone No.:
                                                                                                                Page 2 of 2

                                        ATTACHMENT 1
                            AUTHORIZATION FOR ROTATION CHECK SHEET


A.       DOCUMENTS TO BE SUBMITTED TO CENTER FOR NURSING EDUCATION OFFICE

         Authorization for Rotation Forms must be submitted to the Center for Nursing Education Office at least10 days
         prior to the start of the rotation.

      Authorization for Rotation Form, signed and dated by UCDHS Training Program Director, Rotating Registered
         Nurse and Training Program Director from home institution.

      Copy of insurance certificate and/or letter of indemnity.

      Copy of TB, Rubella, Rubeola, Varicella and Hepatitis clearance (current). Absence of health clearance
         documentation will necessitate the Rotator's go thru by Employee Health Services to obtain clearance before the
         rotator may begin service. TB test is current within a year from the date recorded on the Vaccination
         Administration Record.

      Background check.

B.       DOCUMENTS TO BE RETAINED BY CENTER FOR NURSING EDUCATION

      Listing of Duties, Responsibilities and Privileges.

      Registered Nurse License number and expiration date (include data in auth form).

      CPR Certificate.

      Signed Needle-Stick/Blood-Body Fluid Exposure Policy.

      Signed Confidentiality Agreement.