UNIVERSITY OF SOUTH ALABAMA
                                 COLLEGE OF NURSING
                                   November 2, 2012
                       Clinical Agency Affiliations and Locations

               Agency Name                                      Agency Requirements

15 Place
Mobile, Alabama
Alabama Department of Public Health,
(Alabama inclusive)
Alabama Department of Rehabilitation
Mobile, AL
Allen Memorial Home
Mobile, Alabama
AltaPointe Health Systems, Inc. (formerly
Mobile Mental Health)
Mobile, Alabama
Baldwin County Mental Health
Fairhope, Alabama
Baldwin County Public Schools                    Faculty must notify school prior to clinical experience
Fairhope, Alabama
Baptist Medical Center South (includes Baptist   Students must complete required training before beginning
                                                 training and sign an individual agreement with agency
Medical Center East and Prattville Baptist       (Attachment A).
Montgomery, Alabama
Beverly Healthcare
Foley, Alabama
BMA of Alabama (Dialysis Outpatient Clinic)
Mobile, Alabama
Brookwood Health Services, Inc.                  BSN students: Request Attachments A-C prior to clinical. They
                                                 are Statement of Responsibility, Confidentially Statement,
Birmingham, Alabama
                                                 Background Screening Attestation.

                                                 NP students: Complete Exhibits A-C prior to clinical. Students
                                                 must obtain and maintain commercial general liability
                                                 insurance with an insurer approved by Brookwood. Such
                                                 coverage shall have limits of at least $1,000,000 per
                                                 occurrence and shall not be cancelable except upon 30 days'
                                                 prior written notice to us and to Brookwood. Students must
                                                 provide a copy of their certificate of insurance to us and to
                                                 Brookwood as evidence of said coverage.
Camp Grace, Inc.
Mobile, Alabama
Cathedral Place Apartments
Mobile, Alabama (renewing)
Central Plaza Towers
Mobile, Alabama
Children’s Hospital of Alabama                   Nursing Preceptor & NP Agreement
                                                 Exhibit A (along with other forms) to be completed by faculty and
Birmingham, Alabama                              student prior to placement. FACULTY, PLEASE NOTE:
                                                 Our one page agreement is not required. Children’s Hospital of
                                                 Alabama has a Form of Preceptor Assignment (Exhibit 1.2) this
                              UNIVERSITY OF SOUTH ALABAMA
                                     COLLEGE OF NURSING
                                       November 2, 2012
                           Clinical Agency Affiliations and Locations

                                                   form does not require USA Faculty signature. Form Exhibit 1.2
                                                   will be accepted in lieu of our one page agreement. USA does
                                                   require a signed copy of Exhibit 1.2 for our records.
Children’s Rehab Services
Mobile, Alabama
Coastal Hospice Care, Inc.
Saraland, Alabama
Community Action Agency Head Start of
Baldwin County
Daphne, Alabama
Covenant Hospice
Daphne, Alabama
DCH Hospital Authority (includes Fayette Medical
Center, Northport Medical Center)
Tuscaloosa, Alabama
Dumas Wesley Community Center
Mobile, Alabama
East Alabama Medical Center
Opelika, Alabama
Enterprise Clinic, LLC (d/b/a Hartford Family      Students must pass a test for illegal drugs and
Medicine)                                          unprescribed medications within the 12 months
                                                   preceding each referral or re-referral. Students must
Hartford, Alabama                                  complete Addendum 1 & 2. Nurse Practitioner must
                                                   complete Addendum 3, 4 and 5.
Fayette Medical Center (DCH Hospital Authority)
Fayette, Alabama
Fox Army Health Center
Redstone Arsenal, Alabama
Franklin Primary Health Center, Inc.
Mobile, Alabama
Goodwill Easter Seals Child Development
Mobile, Alabama
Gordon Oaks Healthcare
Mobile Alabama
Healthsouth Rehab Corporation
Mobile, Alabama
Huntsville Hospital (renewing)
Huntsville, Alabama
IMC-Diagnostic & Medical Clinic, P.C.
Mobile, Alabama
Jackson Hospital
Montgomery, Alabama
Little Sisters of the Poor Home for the Aged,
Mobile, Alabama
Lyster U.S. Army Community Hospital                Training for a Nursing Masters Degree
Fort Rucker, Alabama
Marengo Family Health Center
                               UNIVERSITY OF SOUTH ALABAMA
                                      COLLEGE OF NURSING
                                        November 2, 2012
                            Clinical Agency Affiliations and Locations

Demopolis, Alabama
Marshall Health System
Boaz, Alabama
Mercy Medical
Daphne, Alabama
Mobile County Health Department
Mobile, Alabama
Mobile County Public Schools
Mobile, Alabama
Mobile Infirmary Association (includes: Mobile             Faculty must provide Sharon Jones (@ Mobile Infirmary
                                                           435-5089) with spreadsheet with list of NP students.
Infirmary Medical Center, North Baldwin Infirmary,
                                                           Students must complete a 45 minute Healthstream module
Infirmary West, Infirmary LTAC Hospital, E.A. Roberts      for orientation. Once the module has been completed by
Alzheimer’s Center, Thomas Hospital, & Northside Clinic)   student the Letter of Notification will be returned along with
Mobile, Alabama                                            the student badge and parking decal.
Mobile Nursing and Rehabilitation Center, LLC
Mobile, Alabama
Mobile Ob-Gyn, P.C.
Mobile, Alabama
North Baldwin Infirmary
Bay Minette, Alabama
Northport Medical Center (DCH Hospital Authority)
Northport, Alabama
Our Neighborhood Healthcare Clinic
Mobile, Alabama
Pediatrics and Adolescent Medicine PC
Mobile, Alabama
Poarch Band Creek Indians Health
Atmore, Alabama
Princeton Baptist Medical Center,
Birmingham, Alabama
Providence Hospital
Mobile, Alabama
Saad’s Health Care
Mobile, Alabama
Saraland City School System
Saraland, Alabama
Searcy Hospital
Mt. Vernon, Alabama
Seton Medical Management, Inc.
Mobile, Alabama
South Baldwin Family Practice, LLC
Foley, Alabama
South Baldwin Regional Medical Center                      Student must provide written evidence of negative TB test within
                                                           the past year or chest x-ray within last 3 years, written
                                                           documentation of a completed Hepatitis B vaccine or one has
                         UNIVERSITY OF SOUTH ALABAMA
                                COLLEGE OF NURSING
                                  November 2, 2012
                      Clinical Agency Affiliations and Locations

(Foley Hospital)                               begun the series.

Foley, Alabama

Southeast Alabama Medical Center
Dothan, Alabama
Springhill Memorial Hospital
Mobile, Alabama
St. Vincent’s Health System                    Students must sign Confidentiality Statement prior to beginning
                                               clinicals. Clinical faculty please review manual for student
Birmingham, Alabama                            orientation requirements Select link here:
Survivors of Mental Illness (SOMI)
Mobile, Alabama
Thomas Hospital
Fairhope, Alabama
Triad of Alabama, LLC d/b/a Flowers Hospital   Faculty shall review Addendum 1 & 2 with student prior to
                                               student’s clinical rotation.
Dothan, Alabama
Trinity Medical Center (formerly Montclair
Baptist Medical Center)
Birmingham, Alabama
University of Alabama -Birmingham Hospitals
Birmingham, Alabama
University of Alabama, College of Community
Health Sciences, (UMC)
Tuscaloosa, Alabama
University of Alabama (UAB) Montgomery         (Includes-UAB Ambulatory Care Internal Medicine Clinic)

Internal Medicine Residency Program
Montgomery, Alabama
University of South Alabama Hospitals (to      Faculty please request attachments for: Instruction email, Scope
                                               of Physician Participation, and Implementation of eCare.
include the USA Student Health Center)
Mobile, Alabama
USA Mitchell Cancer Institute
Mobile, Alabama
Central Alabama Veterans Healthcare System     BSN and MSN

Montgomery and Tuskegee Alabama
VA Medical Center of Birmingham                BSN-MSN

Birmingham, Alabama
VA Medical Center of Tuscaloosa, AL            BSN and MSN

Tuscaloosa, Alabama
Victory Health Partners
Mobile, Alabama
Westminister Village
                        UNIVERSITY OF SOUTH ALABAMA
                               COLLEGE OF NURSING
                                 November 2, 2012
                     Clinical Agency Affiliations and Locations

Spanish Fort, Alabama
Whatley Health Services
Tuscaloosa, Alabama

              Agency Name                                 Agency Requirements

3rd Medical Group                           Attachment 1 and 2 for Trainee Agreement Addendum
Elmendorf AFB, Alaska
Providence Health & Services – Washington   Non-employees must: complete an Alaska background check;
                                            orientation prior to beginning clinicals.
d/b/a Providence Health & Services Alaska
Region                                      Faculty: Must provide agency with a list of students before they
Anchorage, Alaska                           begin clinicals.

              Agency Name                                 Agency Requirements

Banner Health                               Students are responsible for their own health insurance.
                                            Students are required to complete a BH Orientation which may
                                            include on-line lessons.
Phoenix, Arizona                            Faculty and Students please refer to Exhibit A-Health Standards
                                            (available from the contract office) Students must comply with
                                            OSHA guidelines and training. If students program requirements
                                            include access and experience with patients in isolated rooms,
                                            due to airborne infectious disease, student must have obtained
                                            a respiratory mask-fit testing as required by OSHA.
                                            Students may be asked to submit to a “for cause” drug
                                            screening by BH. Students must agree in writing that BH may at
                                            any time require a “for cause” drug screen, execute a consent
                                            for release of results of such screen information to BH. Student
                                            may be precluded from participating in a Rotation at BH if “for
                                            cause” drug screen is declined or student does not execute a
                                            consent of release.
                                            BH shall conduct a background investigation on (on-site) Faculty
                                            and students participating in the Program at BH. USA shall
                                            provide BH with any information necessary to conduct such
                                            background checks.
                                            Students are not permitted access to the physician parking area
                                            or physician lounge.
                                            Faculty shall provide BH a current copy of the applicable
                                            Program syllabus for all students in each Rotation, as well as
                                            the approved Statement of Objectives for the clinical experience
                                            desired of its students. Faculty shall supply student names no
                                            less than fourteen (14) days prior to Rotation.
                                            Faculty must notify BH of any student placed on the Sanctions
                                            list by the Department of Health and Human Services.
                                UNIVERSITY OF SOUTH ALABAMA
                                       COLLEGE OF NURSING
                                         November 2, 2012
                             Clinical Agency Affiliations and Locations

Phoenix Children’s Hospital                                Student must complete Attachments B & C prior to beginning
Phoenix, Arizona
St. Luke’s Behavioral Health Center                        Confidentiality form, HIPPA form, supervising Physician
                                                           agreement. (Directions available) Students must submit
Phoenix, Arizona
                                                           these forms 14 days prior to beginning clinicals.
University of Arizona, College of Nursing                  Student must be approved prior to beginning clinicals

Tucson, Arizona
VA Phoenix Healthcare System
Phoenix, Arizona

                   Agency Name                                           Agency Requirements

Arkansas Children’s Hospital (renewing)
Little Rock, Arkansas

Arkansas Department of Health & Human                      Students attachments 1 & 2 must be completed prior to starting
                                                           clinicals. See course coordinator.
Services (Arkansas inclusive)                              Arkansas Board of Nursing must be notified by faculty of
                                                           student name, licenses number, preceptor information,
                                                           clinical site, course of enrollment and number of clinical
Central Arkansas Veterans Healthcare System                BSN Degree, RN-BSN, RN-MSN
                                                           Arkansas Board of Nursing must be notified by faculty of
Little Rock, Arkansas                                      student name, licenses number, preceptor information, clinical
                                                           site, course of enrollment and number of clinical hours.

Fort Smith HMA, LLC d/b/a Sparks Health                    Nursing students wishing to participate under this Agreement
                                                           must contact Theresa Phillips in Human Resources 479-441-
System                                                     5458 to set up an appointment to begin the screening and
Fort Smith, Arkansas                                       orientation process.
                                                           Arkansas Board of Nursing must be notified by faculty of
                                                           student name, licenses number, preceptor information, clinical
                                                           site, course of enrollment and number of clinical hours.

                   Agency Name                                           Agency Requirements

Kaiser Foundation Hospitals and the                        Nurse Practitioner Agreement
Permanente Medical Group, Inc., California

Hayward, San Rafael, Oakland, Santa Clara, Redwood City,
Santa Rosa, Richmond, South Sacramento, Roseville, South
                                  UNIVERSITY OF SOUTH ALABAMA
                                         COLLEGE OF NURSING
                                           November 2, 2012
                               Clinical Agency Affiliations and Locations

San Francisco, Sacramento, Vallejo, San Francisco, Walnut
Creek, San Jose

Antioch, Mountain View, Davis, Petaluma, Fairfield, Pleasanton,
Fremont, Rancho Cordova, Fresno, Richmond, Gilroy, Roseville,
Martinez, San Jose, Novato, Stockton, Napa, Vacaville, Milpitas
Hany S. Aziz, MD, Inc.
Bakersfield, California
Northbay Healthcare Group d/b/a Northbay
Medical Center and Northbay Vaca Valley

Fairfield, California

Sharp HealthCare                                                  Faculty: must contact Claudia Bock at 858-499-5366 or by
                                                                  email at to fill out a roster of students
                                                                  being placed at Sharp. Faculty who will be on site with students
San Diego, California                                             need to contact Barbara DeFulvio at 585-499-5244 or
                                                         Faculty web site is

                                                                  Students: need to access the following web site

                                                                  To make sure that the students background checks and drug
                                                                  screening requirements are complete, please see Attachment A.

Success Healthcare, LLC d/b/a Silver Lake
Medical Center

Los Angeles, California

Sutter General Hospital
Sacramento, California
Union County Health Department                                    Students must complete appendices prior to clinicals.

Monroe, North Carolina
VA Greater Los Angeles Healthcare System                          Master of Science

Los Angeles, California

                    Agency Name                                                  Agency Requirements

Denver Health and Hospital Authority                              Term for each student must be agreed upon at least (1) one
                                                                  month prior to the start of clinicals in writing. Faculty must send
                         UNIVERSITY OF SOUTH ALABAMA
                                COLLEGE OF NURSING
                                  November 2, 2012
                      Clinical Agency Affiliations and Locations

Denver, Colorado                           facility the name of each Student enrolled in clinicals, along with
                                           the Attestation Letter (available from the contract office) 30
                                           days prior to clinicals (to provide evidence of: Immune
                                           status for Measles, Mumps, Rubella, and Varicella for
                                           Measles, Mumps, Rubella must provide evidence of two
                                           doses of MMR vaccine if born after 1957, or positive
                                           measles, mumps, rubella titers) and has completed
                                           immunication for Hepatitis B or letter of declination on file.
                                           prior to the beginning of clinicals. Students that work with 12
                                           month olds or younger shall be required to furnish regarding
                                           immunizations and booster protection against pertussis. Student
                                           must have had a PPD test in the past year. If student shows a
                                           past history of positive TB skin test, must show evidence of an
                                           annual assessment to rule out active TB. Students must have
                                           received annual influenza vaccine or declination on file.
                                           Seasonal influenza vaccination is required of all Students
                                           rotating at facility between October and March of each year.

                                           Students must obtain Workers Compensation Insurance
                                           through facility at the Student’s expense, check must be
                                           made payable to DHHA and must be completed 10 days
                                           prior to clinicals. Students must carry health insurance
                                           coverage under an accident and sickness health insurance
                                           plan and must bear the following wording in lieu of the
                                           standard wording; “Should any of the above described
                                           policies be caceled, the issuing company will mail, within
                                           45 days a written notice by Certified Mail to DHHA at 660
                                           Bannock Street, 5th floor, Mail Code 5015, Denvre, CO
                                           80204.”. Students must be 18 years or older.
Evans Army Community Hospital
Fort Carson, Colorado
University of Colorado Hospital            Student must fulfill Attachment A prior to beginning clinicals
                                           Student must fulfill what is outlined in Attachment A prior to
Aurora, Colorado                           beginning clinicals
                                           Faculty and Students: Please send the following documentation
                                           to Kathy Foss ;
                                           Name of student in the clinical experience and anticipated dates
                                           Proof of student’s health insurance
                                           Letter of assurance regarding student’s health status, confirming
                                           all immunizations, including TB testing are up to date.
                                           Current CPR card
                                           Copy of objectives for clinical experience
                                           Completion of UCH’s online orientation program.
VA Medical Center of Grand Junction        MSN students

Grand Junction, Colorado
VA Hospital Denver
Denver, Colorado

              Agency Name                                 Agency Requirements

Naval Health Clinic New England            Coordinators please see contract attachments.
Naval Branch Health Clinic
Groton, Connecticut
                               UNIVERSITY OF SOUTH ALABAMA
                                      COLLEGE OF NURSING
                                        November 2, 2012
                            Clinical Agency Affiliations and Locations

                  Agency Name                                      Agency Requirements

Nemours-Alfred I. DuPont Hospital for
Wilmington, DE

                  Agency Name                                      Agency Requirements

Baker County Health Department
Macclenny, Florida
Baptist Health Care Corporation                       Students please request Exhibit A and B prior to
Pensacola, Florida                                    starting clinicals and bring with you to the Baptist
Includes: Baptist Hospital, Pensacola, FL             Health Care Orientation. Must be completed
        Gulf Breeze Hospital, Gulf Breeze, FL         before clinicals.
        Atmore Community Hospital, Atmore, AL
        Baptist Medical Group, Pace, FL
                                                      Attestation Form must be completed and signed by
                                                      USA Faculty and emailed to Barbara Hamilton-
Baptist Hospital of Miami (to include: Doctors        Faculty must complete Schedule A. Student must complete the
                                                      Student Agreement and Acknowledgement form. Faculty
Hospital, Inc., Homestead Hospital, Inc., South
                                                      must have active Florida license and CPR
Miami Hospital, Inc., Mariners Hospital, Inc., West
                                                      Certification. Please ask for Section 9 School
Kendall Baptist Hospital, Inc., and Baptist           Certification forms.
Outpatient Services, Inc.,)

Bay County Health Department-Florida
Department of Health
Panama City, Florida
Bay Medical Center – Sacred Heart Health
Panama City, Florida
Children’s Med Services, Florida Department
of Health
Panama City, Florida
Citrus County Health Department
Lecanto, Florida
Eglin Air Force Base, 96th Medical                    Undergraduate and graduate nursing degree programs–
                                                      Students must sign the Trainee Agreement Addendum
                           UNIVERSITY OF SOUTH ALABAMA
                                  COLLEGE OF NURSING
                                    November 2, 2012
                        Clinical Agency Affiliations and Locations

Eglin AFB, Florida
Escambia County Health Department
Pensacola, Florida
Florida Department of Health
Includes: Holmes County Health Dept.
Bonifay, Florida
Florida Hospital (Adventist Health           Student must be N-95 respirator fit tested prior to attending
                                             clnical. Testing can be done for $25 at the Agency clinic.
System/Sunbelt, Inc.)
                                             General Nursing and PT Students please see Exhibit C –
Maitland, Florida                            Criminal Background Disqualifications Guidelines.

Florida State Hospital
Chattahoochee, Florida
Fort Walton Beach Medical Center             Student must take Compliance test from agency prior to
                                             beginning clinical rotation. Also exhibits must be completed.
Ft. Walton Beach, Florida                    Agency requires modified Letter of Notification –Students must
                                             have a 10 panel drug screen, faculty please contact CON
                                             contracts department.
Gulf Coast Medical Center
Panama, City, Florida
Holmes County Department of Health
Bonifay, Florida
Holmes Regional Medical Center               **Faculty please see me regarding “specific responsibilities”
Melbourne, Florida
James A. Haley Veteran’s Hospital
Tampa, Florida
Kindred Healthcare System
Green Cove Springs, Florida
Lakeview Center, Inc.
Pensacola, Florida
Lakewood Ranch Medical Center
Bradenton, Florida
Lee Memorial Health System
Cape Coral, Florida
Madison Nursing Center
Madison, Florida
Memorial Healthcare Group, Inc., d/b/a       Student must complete Exhibits A-C prior to beginning clinicals.
Memorial Hospital
Jacksonville, Florida
Miami Children’s Hospital                    Attachment A must be submitted on an annual basis not less
                                             than 60 days prior to the commencement of each period of
Miami, Florida                               clinical assignment. Faculty please see CON Contracts Dept for
                                             Attachment A.
Moffitt Cancer Center                        RN-BSN, BSN, RN-MSN, and DNP programs.
Tampa, Florida                               Schedule 4.8 Screenings and Vaccination

                                             Schedule 4.9 Student Letter Agreement, must be completed by
Munroe Regional Medical Center               Student must contact Workforce Development Coordinator with
                                             Munroe to complete orientation packet prior to beginning
Ocala, Florida                               clinicals.
Naples Community Hospital, NCH Healthcare
                          UNIVERSITY OF SOUTH ALABAMA
                                 COLLEGE OF NURSING
                                   November 2, 2012
                       Clinical Agency Affiliations and Locations

Naples, Florida
Naval Hospital                                   Contract includes: Allied Health students
                                                 Students are required to complete a confidentiality statement
Pensacola, Florida                               prior to clinical experience (See faculty)
Nemours Foundation (includes Children’s
Clinic in Destin, FL)
Pensacola, Florida
Neonatology Associates of Atlanta, P.C.
Sunrise, Florida (corporate office)
North Okaloosa Medical Center
Crestview, Florida
Nurse Practitioner On Call
Pensacola, Florida
Oak Hill Hospital                                Students must complete Exhibits A & B prior to beginning
                                                 clinical rotation. USA CON must complete Exhibit C on behalf of
Brooksville, Florida                             student(s).
Orlando Health, Inc.                             Schedule B Requirements for Participants on file
Orlando, Florida
Okaloosa County Health Dept.
Fort Walton Beach, Florida
Palm Beach County Health Department,
West Palm Beach, Florida
Plantation General Hospital                      Students must complete Exhibits A, B, & C before
                                                 beginning clinicals. NNP students must have signed
Plantation, Florida                              agreement with Sheridan.

Rural Health Care, Inc., d/b/a Family Medical
& Dental Centers

Palatka, FL

Sacred Heart Health System                       Students must review Exhibit A and complete Application for
                                                 Residents and Students prior to starting clinicals. See course
Pensacola, Florida                               coordinators .Students must follow flu vaccine policy, available
                                                 through the contract office.
Santa Rosa Public Health Department
Milton, Florida
Shands Jacksonville Medical Center               ALL REQUESTS FOR CLINICAL ROTATIONS MUST COME
                                                 FROM FACULTY. Faculty should contact Sophia Akley,
Jacksonville, Florida                            Education Director, at (904) 244-1925 and she will provide
                                                 Shands’ orientation packet. Students must have photo student
                                                 ID and complete Shands’ orientation prior to beginning clinicals.
                                                 Exhibit A requirements from student and faculty.
Shands Teaching Hospital and Clinics d/b/a       Students must complete Exhibit A before starting clinicals.

Shands at the University of Florida (Shands at
Vista and Shands Rehab Hospital)
Gainesville, Florida
                             UNIVERSITY OF SOUTH ALABAMA
                                    COLLEGE OF NURSING
                                      November 2, 2012
                          Clinical Agency Affiliations and Locations

Sheridan Children’s Healthcare Services and           Faculty must submit Letter of Understanding to Memorial
South Broward Hospital District d/b/a Memorial        for each student. Student may be required to purchase
                                                      general liability insurance if applicable.
Healthcare System (Memorial includes: Memorial
Regional, Memorial Regional Hospital South, Joe
DiMaggio Children’s Hospital, Memorial Hospital
Pembroke, Memorial Hospital West, Memorial Hospital

Hollywood, Florida

South Broward Hospital District d/b/a Memorial        Masters in Nursing Program, Neonatal NP

Healthcare System
Hollywood, Florida
Tallahassee Memorial HealthCare, Inc.                 Students must complete TMH’s attachments and orientation
                                                      prior to beginning clinicals.
Tallahassee, Florida
Tampa General Hospital (Florida Health                Contract only to be used as a 3-way
Science Center) (including Florida Gulf to            agreement with Tampa General/Gulf to
Bay Anesthesiology Associates, PA)                    Bay/University of South Alabama
Tampa, Florida
Twin Cities Hospital
Niceville, Florida
University Community Hospital d/b/a Florida           Students must assume responsibility for and maintain
Hospital Tampa                                        health insurance.

                                                      Provide agency with documentation of their criminal
Tampa, Florida                                        background check and immunizations.

University of Florida, College of Medicine,
OBGYN Department
Pensacola, Florida
University of Florida, College of Medicine            Students must complete Exhibit A prior to beginning clinicals.
                                                      This includes a 12 panel drug screen.
Jacksonville, Florida
James A. Haley Veterans Hospital                      RN-BSN, Master of Science, Doctor of Nursing Practice

Tampa, Florida
VA Healthcare Center of Bay Pines                     BSN, MSN, DNP
                                                      Student must contact agency to be fingerprinted 1 month prior to
Bay Pines, Florida                                    rotation. Student cannot begin until results are back.
Veterans Affairs North Florida/South Georgia          RN-BSN/BSN & MSN

Health System
Gainesville, Florida
Walton County Health Department
Defuniak Springs, Florida
West Florida Hospital
                                  UNIVERSITY OF SOUTH ALABAMA
                                         COLLEGE OF NURSING
                                           November 2, 2012
                               Clinical Agency Affiliations and Locations

Pensacola, Florida

White-Wilson Medical Center                                   Advanced Registered NP Agreement (agency requires separate
                                                              agreement for each student). FACULTY – please distribute
Fort Walton Beach, Florida                                    WWMC’s Protocol to student. Students should inquire at
                                                              Administration (850-863-8131) to determine if a
                                                              physician/specialty is available. Students should NOT
                                                              contact physicians themselves; Administration will contact
                                                              the physician for the student.
Wolfson Children’s Hospital
Jacksonville, Florida

                    Agency Name                                              Agency Requirements

Appling Health Care System
St. Baxley, Georgia
Children’s Healthcare of Atlanta (covers                      Students must complete Exhibits A, B-1, and C prior to clinical.
Egleston and Scottish Rite)
Atlanta, Georgia
Dekalb Medical Center                                         Nurse Practitioner Agreement to include DNP students.
Decatur, Georgia
Doctors Hospital of Augusta (expired-                         Students must complete Exhibit B as well as the Statement of
                                                              Responsibility prior to starting clinicals (see faculty)
Augusta, Georgia
Dwight David Eisenhower Army Medical
Fort Gordon, Georgia
Emory University Hospital includes:[Emory                     Students please request attachments from the course
Crawford Long Hospital, Wesley Woods Center, Emory            coordinator. These documents must be completed prior to
University Orthopedic and Spine Hospital, The Emory Clinic,   clinicals.
Emory Children’s Center]
Atlanta, Georgia
Georgia Dept. of Health, West Central Health
Columbus, Georgia
Georgia Health Science Health Inc. (formerly                  Please contact Angela McIntosh, Clinical Nurse Educator, at
                                                              (706) 721-0305 or via email to
Medical College of Georgia)
Augusta, Georgia
Georgia Southern University
Statesboro, Georgia
Grady Health System                                           Students notify faculty prior to starting clinicals. Faculty should
                                                              see contract person regarding exhibits for students to complete.
Atlanta, Georgia
Gwinnett Hospital System, Inc.(renewing)                      NNP students only – preceptor Dr. Leslie Leigh;
                                                              Students must review Exhibit “A” Permitted Activities of the
Lawrenceville and Duluth, Georgia                             Student
Harbin Clinic
                               UNIVERSITY OF SOUTH ALABAMA
                                      COLLEGE OF NURSING
                                        November 2, 2012
                            Clinical Agency Affiliations and Locations

Rome, Georgia
Health District 8, Unit 2                        (Southwest Georgia Health District) (encompasses clinical
                                                 facilities in Georgia counties of Baker, Calhoun, Colquitt,
Albany, Georgia                                  Decatur, Dougherty, Early, Grady, Lee, Miller, Mitchell,
                                                 Seminole, Terrell, Thomas & Worth)
Hospital Authority of Valdosta and Lowndes
County, GA d/b/a South Georgia Medical
Martin Army Community Hospital                   BSN and graduate students
Fort Benning, Georgia
Meadows Healthcare Alliance                      Only allows students into agency’s Wellness Center for sports
                                                 medicine clinicals.
Vidalia, Georgia
Meadows Regional Medical Center
Vidalia, Georgia
Medical Center of Central Georgia
Macon, Georgia
Memorial Hospital University Medical Center      Student must complete attachments A through G and
                                                 Verification of Student Information
Savannah, Georgia
Mercy Care Services, Inc.
Atlanta, Georgia
MHM Services, Inc.                               Student may have to purchase Worker's Compensation and
                                                 General Liability Insurance at agency's request.
Atlanta, Georgia
                                                 Student must have current Health Insurance and provide agency
                                                 with documentation.

Northeast Georgia Medical Centers, Inc.          Graduate Students
(Northeast Georgia Health System)
Gainesville, Georgia

Northside Hospital                               At time of enrollment in the program: student will need to
                                                 have a physical exam (to include: PPD test or chest x-ray,
                                                 hepatitis -B core antibody test, and Rubella and Measles test or
Atlanta, Georgia
                                                 documentation of immunization).

Patient Care Services
Decatur, Georgia
Phoebe Putney Memorial Hospital

Albany, Georgia
Piedmont Healthcare, Inc.                        Must provide student placement coordinator a statement that
                                                 student has a negative drug screen and background check.
                                                 Student must all orientation paperwork on the following website:
Atlanta, Georgia                        . Faculty will need to
                                                 sign the signature page verifying the student has reviewed the

Planned Parenthood Southeast, Inc.
Atlanta, Georgia
Rockdale Medical Center
Conyers, Georgia
                           UNIVERSITY OF SOUTH ALABAMA
                                  COLLEGE OF NURSING
                                    November 2, 2012
                        Clinical Agency Affiliations and Locations

St. Francis Hospital, Inc.                   Students must complete Exhibits A & B prior to beginning
Columbus, Georgia (renewing)
St. Joseph’s /Candler Health System          Acute Care, Emergency, MSN Family, and Pediatric Nurse
                                             Practitioners only.
Savannah, Georgia                            Faculty please see Exhibit A (agency attachments list)
                                             Student must have current physical. Students must maintain
                                             health insurance with proof to agency being provided upon
Saint Joseph’s Hospital of Atlanta, Inc.     Students must complete Exhibit B prior to starting clinicals.
                                             Faculty and student must read and sign “Standards of Conduct”
Atlanta, Georgia                             form. Faculty should contact Contract person at CON.
Southeastern Regional Primary Care
Vidalia, Georgia
Tanner Medical Center, Inc.
Carrollton, Georgia
Tenet Health System GB, Inc. (dba Atlanta    Student attachments required prior to starting clinicals. Please
                                             request Exhibit A and B from faculty.
Medical Center)
Atlanta, Georgia
The Medical Center, Inc.                     Student must carry their own occurrence-type general and
                                             professional liability insurance coverage in amounts not less
Columbus, Georgia                            than $1,000,000 per occurrence and $3,000,000 annual
United HealthCare Services, Inc.             Students must complete attachments prior to clinicals-See
d/b/a Evercare Georgia,
Norcross, Georgia
VA Medical Center of Atlanta                 MSN in Gerontology NP
Atlanta, Georgia
VA Medical Center of Carl Vinson             NP: Masters Program

Dublin, GA
VA Medical Center of Charlie Norwood         Nursing (MSN-GNP Degree Programs)
                                             DNP Students
Augusta, Georgia
WellStar Health System, Inc. (to include:    Only WellStar employees are eligible. Students must complete
                                             an orientation packet prior to beginning any clinical rotation.
Cobb, Kennestone, Paulding, Douglas, and
Windy Hill)                                  Faculty please complete the organizational Learning form for
                                             each semester for each program at a Well Star facility (form
                                             available in the attachments folder).
Marietta, Georgia

West Georgia Medical Center
LaGrange, Georgia

               Agency Name                                 Agency Requirements

Hawaii Pacific Health                        Students must review Exhibit “A” Standards of Conduct
                          UNIVERSITY OF SOUTH ALABAMA
                                 COLLEGE OF NURSING
                                   November 2, 2012
                       Clinical Agency Affiliations and Locations

Honolulu, Hawaii
Kaiser Foundation Hospitals, Hawaii Region
and the Kaiser Foundation Health Plan Inc.,
Hawaii Region
Tripler Army Medical Center
Honolulu, Hawaii
VA Pacific Islands Health Care System            MSN students only

Honolulu, Hawaii

               Agency Name                                      Agency Requirements

Boise VAMC
Boise, Idaho
Eastern Idaho Health Services
Idaho Falls, Idaho
Idaho Department of Health and Welfare State
Hospital North
Orofino, Idaho
St. Alphonsus Physicians Services, Inc.          Students must complete Attachments prior to starting clinicals—
                                                 See faculty
Boise, Idaho (renewing)
Saint Alphonsus Regional Medical Center          Faculty and Students please see Attachments A-1, A-2, B, and
                                                 the signature page, available through the Contracts Office. Saint
Boise, Idaho
                                                 Alphonsus requires a negative TB skin test or chest x-ray within
                                                 the last 12 months, a hepatitis B vaccination or documentation
                                                 of positive HB Sab, or a signed declination, verification of
                                                 varicella (chicken pox) status.

St. Luke’s Health System, Ltd. (to include St.   Faculty will contact agency no less than 30 days prior to clinical
                                                 in order for St. Luke’s to determine capacity. At least 15 days
Luke’s Regional Medical Center –Boise &          prior to clinical Faculty must provide student information and
Meridian, St. Luke’s Eagle Medical Plaza, and    documentation to facility. Students must complete Attachment
                                                 B. Agreement covers all Nurse Practitioner and Nursing
St. Luke’s Clinics

Boise, Idaho

               Agency Name                                      Agency Requirements
                         UNIVERSITY OF SOUTH ALABAMA
                                COLLEGE OF NURSING
                                  November 2, 2012
                      Clinical Agency Affiliations and Locations

University of Chicago Medical Center          Faculty must provide a written description of the program and
                                              objectives of the courses and the approximate number of
                                              students to be assigned at any given time in the units. The
Chicago, Illinois                             names of the students shall be submitted three weeks prior to
                                              the beginning of the semester. USA must provide the names
                                              and credentials of the faculty who will participate in the Program

Northwestern Memorial Hospital                Students must complete Exhibit 1 prior to clinicals.
Chicago, Illinois
VA Medical Center of Marion, IL               Master of Science

Marion, Illinois

                Agency Name                                 Agency Requirements

Floyd Memorial Hospital and Health Services
New Albany, Indiana
Scott Memorial Hospital
Scottsburg, Indiana

                Agency Name                                 Agency Requirements

Mercy Medical Center                          Exhibit A must be completed and signed by student.
Des Moines, Iowa
VA Central Iowa Health Care System            CNL students only

Knoxville and Des Moines Divisions

                Agency Name                                 Agency Requirements

                           UNIVERSITY OF SOUTH ALABAMA
                                  COLLEGE OF NURSING
                                    November 2, 2012
                        Clinical Agency Affiliations and Locations

               Agency Name                                       Agency Requirements

Baptist Healthcare System, Inc. d/b/a Central      Student must sign Statement of Understanding and
                                                   Confidentiality Agreement.
Baptist Hospital
Lexington, Kentucky
Blanchfield Army Community Hospital
Fort Campbell, Kentucky
Jewish Hospital & St. Mary’s Healthcare, Inc.      Exhibits A & B must be completed prior to beginning clinical
                                                   rotation. In addition, School must verify negative status of
d/b/a Jewish Hospital                              Kentucky Board of Nursing Abuse Registry check prior to
Louisville, Kentucky                               commencement of the clinical experience.
Our Lady of Bellefonte Hospital
Ashland, Kentucky
Norton Healthcare (Norton Kosair Children’s        NP Students.
Hospital, Norton Suburban Hospital, Norton         Faculty must schedule/coordinate clinical experience
                                                   with facility at least 6 weeks in advance of clinicals.
Audubon Hospital, Norton Hospital, and
Norton Brownsboro Hospital) and Neonatal
Louisville, Kentucky
Trover Foundation/Trover Health Services           Students must provide copies of all immunization records to the
                                                   site Clinical Education coordinator
Madisonville, Kentucky
University of Kentucky Medical Center
Lexington, Kentucky
University Medical Center, Inc. d/b/a University   Students must fulfill requirements as outlined in Exhibit A and
                                                   sign Exhibit B (Statement of Understanding and Confidentiality
of Louisville Hospital/James Graham Brown          Agreement)
Cancer Center
Louisville, Kentucky

               Agency Name                                       Agency Requirements

Baton Rouge General Medical Center                 Physical Therapy, Occupational Therapy and Nursing Students
Baton Rouge, Louisiana
Children’s Hospital
New Orleans, Louisiana
Christus Health Northern Louisiana
Shreveport, Louisiana
Dauterive Hospital (renewing)
New Iberia, Louisiana
East Jefferson General Hospital                    Nursing Preceptor Agreement Only.
                                                   Faculty needs to provide roster of students, etc.
Metairie, Louisiana                                *Students must submit a letter to CNO regarding goals outlined
                                                   by the school and the student for the practicum and a copy of
                                                   the student’s current vitae.
                                                   *Graduate students must be interviewed by EJGH oversight
                          UNIVERSITY OF SOUTH ALABAMA
                                 COLLEGE OF NURSING
                                   November 2, 2012
                       Clinical Agency Affiliations and Locations

                                                 committee members to discuss mutual goals and objectives.
                                                 *Students must have preceptor selected by Director of CNKR
                                                 and meet with preceptor prior to starting practicum.
Iasis Glenwood Regional Medical Center, LP       Students must complete Exhibit A, “Confidentiality Statement”
                                                 prior to beginning clinical rotation.
d/b/a Glenwood Regional Medical Center
West Monroe, Louisiana

Health Care Centers in Schools
Baton Rouge, Louisiana
Iberia Medical Center (Jeanerette Rural Health
New Iberia, Louisiana
Lafayette General Medical Center                 9 panel drug screen
Lafayette, Louisiana
Lakeland Medical Center
New Orleans, Louisiana
Lallie Kemp Medical Center
Independence, LA
Leonard J. Chabert Medical Center –LSU
Hospitals Health Care Services Division
Houma, Louisiana
LSU Health Sciences Center                       Faculty must submit in writing their requests for clinical sites for
                                                 each rotation. Contact USA contract dept for agency contact
Shreveport, Louisiana                            info, Exhibit A and A #2.
(Earl K. Long Medical Center to close            Students must provide verification of negative TB skin test
                                                 within the past 12 months or follow up negative chest x-ray
inpatient services as of May 2013)               result.
Medical Center of Louisiana at New Orleans or    *Name Alert* Due to Hurricane Katrina, this site has a new
                                                 name (Louisiana State University Interim Hospital)
(LSU Interim Hospital)
New Orleans, Louisiana
North Oaks Health System (includes North         Students must notify agency clinical coordinator prior to starting
                                                 clinicals Must be in compliance with Louisiana State Board of
Oaks Rehabilitation Hospital                     Nursing. Only selected students may participate that have
Hammond, Louisiana                               completed prerequisite portion of curriculum. USA CON must
                                                 complete Exhibit 1 Pre-Assignment Results Form prior to
                                                 student beginning clinicals.
NorthShore Regional Medical Center               Exhibits A & B must be signed by student
Slidell, Louisiana
NorthShore Specialty Hospital
Covington, Louisiana
Ochsner Clinic Foundation                        Exhibits A & B must be signed by student, a drug screen from a
                                                 SAMSA approved laboratory within one week of starting
New Orleans, Louisiana                           clinicals, a criminal background check, a PPD within the last 6
                                                 months, copy of current BLS card, and proof of positive titers for
                                                 measles, mumps, rubella, and varicella
Includes all 32 regional clinics (Slidell,
Covington, etc.)
Ochsner Medical Center                           Exhibits A & B will need student signatures
Kenner, Louisiana
Ochsner Medical Center, as part of Ochsner       Contract includes DNP Students.
                                                 Students must complete Exhibit A & B prior to starting clinicals
Clinic Foundation West Bank, LLC                 (see course coordinator)
Includes: East Baton Rouge Medical Ctr.
New Orleans, Louisiana
                          UNIVERSITY OF SOUTH ALABAMA
                                 COLLEGE OF NURSING
                                   November 2, 2012
                       Clinical Agency Affiliations and Locations

Ochsner St. Anne General Hospital              Students must complete Exhibit A (Statement of Responsibility)
                                               & Exhibit B (Confidentiality Statement) prior to beginning
New Orleans, Louisiana                         clinicals.
Our Lady of the Lake Ascension Community
Hospital, Inc. d/b/a St. Elizabeth Hospital    Students must complete Attachment 1 (Student Agreement),
                                               Attachment 2 (Confidentiality Agreement), and Attachment 3
Gonzales, Louisiana                            (Statement of Responsibility) prior to beginning clinicals.
Our Lady of the Lake Assumption Community
                                               Students must complete and sign Attacments 1-3
Hospital, Inc.

Nepoleonville, Louisiana

Our Lady of the Lake Physician Group, LLC      Students must complete Attachments 1-3 prior to beginning

Baton Rouge, Louisiana

Our Lady of the Lake Regional Medical Center   Prior to contacting agency, students must have a
                                               background check, TB skin test, and a CURRENT (within 1
Baton Rouge, Louisiana                         semester) drug screen, and complete Attachments 1-3. If
                                               using a non-OLOL employed physician or third level, the
                                               Revised Sponsoring Physician Letter must be signed prior
                                               to meeting with Dr. Steele-Moses. Students/faculty should
                                               contact Dr. Susan Steele-Moses, Program Director for Nursing
                                               Research prior to beginning clinicals to ensure compliance with
                                               all requirements. Agency must receive electronic clinical
                                               objectives. Program Director must receive specific dates
                                               student will be in this facility. Agency will visually check RN
                                               licensure and current CPR prior to student beginning at this
                                               To include PNP program.

Our Lady of Lourdes Regional Medical Center
Lafayette, Louisiana
Regional Medical Center of Acadiana            Students must sign Exhibits A and B prior to beginning clinicals.

Lafayette, Louisiana (renewing)
Slidell Memorial Hospital & Medical Center,
Slidell, Louisiana
St. Francis Medical Center, Inc.               Attachment 1,2 and 3
Monroe, Louisiana                              Exhibit A RN-BSN program

                                               Exhibit B MSN program

                                               Exhibit C DNP program

The Baton Rouge Clinic, AMC                    Faculty must verify annually that the student has :
                                               TB skin Test (annually)
Baton Rouge, Louisiana                         Up to date Immunization History
                                               Criminal Background check for the past 7 years including
                                               Residency History
                                               Nationwide Database with Sex Offender Index and Healthcare
                                               Fraud & Abuse
                                               Social Security Alert
                                               Urine Drug Screen
                                               Faculty, please ask Contract Office for Credential/Administrative
                           UNIVERSITY OF SOUTH ALABAMA
                                  COLLEGE OF NURSING
                                    November 2, 2012
                        Clinical Agency Affiliations and Locations

St. Tammany Parish Hospital
Covington, Louisiana
Thibodaux Regional Medical Center
Thibodaux, Louisiana
Touro Infirmary                               Faculty must complete Exhibit A. Student must complete Exhibit
                                              B prior to clinicals.
New Orleans, Louisiana
Tulane University Medical Group (Department
of Pediatrics)
New Orleans, Louisiana
VA Medical Center of Alexandria, LA           Gerontological/Adult Psychiatric NP (On-Line) Bachelor and
Alexandria, Louisiana
VA Medical Center of New Orleans              Master of Science

New Orleans, Louisiana
VA Medical Center of Overton Brooks           Undergraduate & Graduate degrees in Science of Nursing
                                              TQCVL Paperwork in file.
Shreveport, Louisiana
Willis-Knighton Health System (Agreement is   Student is responsible for their own personal health care
student specific for each student)
                                              Student must have a Fit Test for the N95 Respirator and is
Shreveport, Louisiana                         responsible for the cost of test.

                                              Students please see Flu Shot Memo and Declination of
                                              Seasonal Influenza Vaccine.

                                              Students must register within the agency's database -complete
                                              orientation packet and return all documentation to agency 21
                                              days prior to clinical rotation (please see attachments).

                                              Faculty must submit a request to agency 60 days prior to
                                              student's clinical rotation.

Women’s and Children’s Hospital               Agency requires a company 10 panel drug screen. Students
                                              must also complete Exhibits A & B prior to beginning clinical
Lafayette, Louisiana                          rotation.

              Agency Name                                   Agency Requirements

Eastern Maine Medical Center
Bangor, Maine
                         UNIVERSITY OF SOUTH ALABAMA
                                COLLEGE OF NURSING
                                  November 2, 2012
                      Clinical Agency Affiliations and Locations

              Agency Name                                   Agency Requirements

Franklin Square Hospital Center (a Med Star   Faculty and Student: Read and Complete Exhibits A-D (to
                                              include health screening requirements), Attachment B
Entity)                                       (Certificate of Student Requirements must be provided to
                                              agency within 30 days prior to beginning clinicals . Criminal
Rosedale, Maryland                            background check and Drug Test must be done within
                                              twelve (12) months prior to start of clinicals. Students
                                              must maintain adequate health insurance. Faculty will
                                              provide agency with the names of students forty-fine (45)
                                              days prior to their arrival.

Frederick Memorial Hospital                   Faculty and Students please read the Policies and Procedures

Frederick, Maryland

Mercy Health Services
Baltimore, Maryland
NIH Clinical Center
Bethesda, Maryland
University of Maryland Medical Center         Student must complete Attachment A prior to beginning clinicals.

Baltimore, Maryland

              Agency Name                                   Agency Requirements

Massachusetts General Hospital (General       Student must have had a “no record” result from
Hospital Corp)                                their national county criminal background check no
                                              later than 3 months prior to the beginning of their
Boston, Massachusetts                         clinicals.. If check reveals that record(s) exist, the student
                                              must contact the facility’s Police and Security Dept. at (617)
                                              724-4337 and received a determination, consistent with
                                              applicable law and facility policies, that they may continue with
                                              Students must be covered by a health insurance policy.
                                              Students must complete Confidentiality Agreement prior to
                                              beginning clinicals. Students must also review the following:
                                              “Physical Removal & Transport of Protected Health Information
                                              & Personal Information,” “Laptop Encryption Policy,” & “Portable
                                              USB Drive Encryption” in addition to completing the
                                              HEALTHSTREAM training module.
Southcoast Hospitals Group, Inc.              Students and on-site instructors must complete 10 panel urine
                                              drug test prior to beginning clinicals. Students must complete
                                              the student/Instructor Confidentiality Agreement.
New Bedford, Massachusetts
                          UNIVERSITY OF SOUTH ALABAMA
                                 COLLEGE OF NURSING
                                   November 2, 2012
                       Clinical Agency Affiliations and Locations

UMASS Memorial Medical Center, Inc.          USA Faculty must provide UMMMC with a Program schedule of
                                             clinical days and dates as well as the number and names of
                                             Students and Faculty to be assigned to the Program. This must
Worchester, MA                               be submitted at least two weeks prior to the start of the relevant
                                             Program period. Students must complete Orientation forms prior
                                             to beginning clinicals.

VA Medical Center of Northhampton, MA        Graduate Degree

Leeds, MA

               Agency Name                                 Agency Requirements

Allegan Healthcare Group                          Faculty and Students please read Exhibit A

Allegan, Michigan

Oakwood Healthcare, Inc.
Dearborn, Michigan
Saint Mary’s of Michigan Standish Hospital
Saginaw, Michigan
University of Michigan Health System
Ann Arbor, Michigan
VA Medical Center of Ann Arbor               Nursing Program, Master’s

Ann Arbor, Michigan

               Agency Name                                 Agency Requirements

Children’s Healthcare d/b/a Children’s       Students must complete the online registration
Hospitals & Clinics of Minnesota             at least 2 weeks prior to the beginning of
Minneapolis, Minnesota                       clinicals (no exceptions).
Fairview Health Services                     DNP students only
Minneapolis, Minnesota
Hennepin County Medical Center               Students must cooperate with HCMC in obtaining a Minnesota
                                             Background study before beginning clinicals.
Minneapolis, Minnesota

North Memorial Health Care                   Minnesota RN license required for Faculty.
                           UNIVERSITY OF SOUTH ALABAMA
                                  COLLEGE OF NURSING
                                    November 2, 2012
                        Clinical Agency Affiliations and Locations

Robbinsdale, Minnesota
St. Cloud VA Medical Center
St. Cloud, Minnesota
University of Minnesota Physicians
Minneapolis, Minnesota

               Agency Name                                       Agency Requirements

Baptist Memorial Hospital – Golden Triangle
Columbus, Mississippi
Biloxi Regional Medical Center                    Following is required prior to clinicals by Mississippi Department
                                                  of Health: Background check state of MS. (addl Fee), MMR,
Biloxi, Mississippi                               PPD-must be within 1 year of expected date of completion of
                                                  clinical rotation. Health and must have a MS background check
                                                  prior to background screening attestation form (Exhibit C) being
                                                  completed by University Official. Faculty must provide schedule
                                                  for the length of time the students will be in the facility 14 days
                                                  prior to rotation.
Coastal Family Health Center (to include the      Faculty: please call Ms. Chris Maurice at 228-974-2494 xt.
                                                  1019 to coordinate preceptor.
following clinics: Bay St. Louis, Gulfport,
Saucier, Biloxi, Children’s Health Fund Mobile
Unit, Vancleave, Gulfport II, Pass Christian,
Biloxi, Mississippi
Delta Regional Medical Center
Greenville, Mississippi (renewing)
George Regional Health Systems
Lucedale, Mississippi
Gulf Coast Mental Health Center
Gulfport, Mississippi
Gulfport School District
Gulfport, Mississippi
Jeff Anderson Regional Medical Center
Meridian, Mississippi
Keesler Medical Center, 81st Medical Group,       Master of Science in Nursing
Keesler AFB, Mississippi
Memorial Hospital at Gulfport                     (Indoor and Outdoor) Tobacco free environment
                                                  Fingerprinting is required. Student pays $50 fee to hospital.
Gulfport, Mississippi
Mississippi Baptist Health Systems, Inc.,
Mississippi Baptist Medical Center, Inc., and
Mississippi Hospital for Restorative Care, Inc.
Jackson, Mississippi
Mississippi State Department of Health            Faculty please make arrangements for clinical locations
                                                  and times with the county coordinating nurse/and or the
Jackson, Mississippi                              district chief nurse. County health department contact
                                                  information can be found on the MSDH website at
                           UNIVERSITY OF SOUTH ALABAMA
                                  COLLEGE OF NURSING
                                    November 2, 2012
                        Clinical Agency Affiliations and Locations

                                    under the location tab. District chief
                                             nurse list is on the agency attachments list.

Mississippi State Hospital (renewing)
Whitfield, Mississippi
North Mississippi Health System              BSN and MSN Students—Attachments required prior to
                                             clinicals. Faculty, please see me regarding attachments.
Tupelo, Mississippi
North Mississippi Medical Clinics, Inc.
                                             Students must complete and sign the attached Student Program
Tupelo, Mississippi                          Agreement, Health Advisory, and Background Affidavit prior to
                                             beginning clinicals.
                                             Students must obtain and maintain personal and professional
                                             liability insurance with coverage and amounts determined by
                                             Students must not be an employee of NMMCI within the
                                             meaning of the Mississippi Workers' Compensation Law.
North Mississippi State Hospital
Tupelo, Mississippi
River Oaks Hospital
Jackson, Mississippi
River Oaks Woman’s Hospital
Jackson, Mississippi
Rush Foundation Hospital (Rush Health
Meridian, Mississippi
Select Specialty Hospital
Gulfport, Mississippi
Singing River Hospital System, (Includes
Singing River and Ocean Springs Hospitals)
Pascagoula, Mississippi
South Central Regional Medical Center        RN to BSN, graduate students
                                             Grad students please see Ms. Beth Endom
Laurel, Mississippi                          prior to starting
South Mississippi Home Health, Inc.
Hattiesburg, Mississippi
Southwest Mississippi Regional Medical
McComb, Mississippi
The Diabetes Center
Ocean Springs, Mississippi
University of Mississippi Medical Center     Students must complete Epic System Training. Visit
                                             affiliated student webpage, then click on
Jackson, Mississippi                         Education tab, then affiliated students under Resources.
Veterans Affairs Gulf Coast Healthcare       Nursing: BSN, MSN, and graduate students
                                             Agency requires Trainee Qualifications and Credentials
System                                       Verification Letter (TQCVL) signed by Program Director.
Biloxi, Mississippi                          Students must go to the VA Gulf Coast in Biloxi to “Process
                                             In” this includes fingerprinting 7-120 days prior to rotation,
                                             once that is complete must return there to be issued their
                            UNIVERSITY OF SOUTH ALABAMA
                                   COLLEGE OF NURSING
                                     November 2, 2012
                         Clinical Agency Affiliations and Locations

                                               Faculty: Agency may request a Clinical Instructor Profile form
                                               filled out.
VA Medical Center - G.V. (Sonny)               Occupational Therapy – MS
                                               Nursing – Acute NP (Masters)
Montgomery                                     Nursing – Geri Psych NP (Masters)
Jackson, Mississippi                           Nursing – Family NP (Masters)
                                               Nursing – BSN
                                               Nursing – MSN
                                               Masters-ENP Program
                                               Clinical Nurse Leader (MSN)
Vicksburg Healthcare, LLC d/b/a River Region     Students must submit to substance abuse testing every 12
                                                 months (to test for presence of alcohol, drugs, or other
Health System                                    controlled substances).

Vicksburg, Mississippi

Wesley Medical Center                          “Student Agreement Only”-Students should complete a Term
                                               Sheet from the agency Now includes FNP students
Hattiesburg, MS

               Agency Name                                   Agency Requirements

Children’s Mercy Hospital and Clinics
Kansas City, Missouri
Family Health Care Center (renewing)           Faculty, any correspondence with preceptors must be copied to
                                               Mr. Dennis Kruse, CFO-401 Holly Hills Avenue, St. Louis, MO
Saint Louis, Missouri                          63111-2410
ReHab Care (renewing)
Austin, TX or St. Louis, MO
Heartland Regional Medical Center              Student must complete a Missouri Background check,
                                               recommendations can be found at www.heartland-
St. Joseph, Missouri                  Students and Faculty are not allowed to
                                               enter airborne isolation areas.
Northwest Missouri Psychiatric Rehab Center
St. Joseph, Missouri
St. Louis Children’s Hospital                  Faculty, please request a copy of the “additional terms” form
                                               prior to students beginning clinicals
St. Louis, Missouri
St. Luke’s Northland Hospital
Kansas City, Missouri
VA Medical Center of St. Louis, MO
St. Louis, Missouri

               Agency Name                                   Agency Requirements
                         UNIVERSITY OF SOUTH ALABAMA
                                COLLEGE OF NURSING
                                  November 2, 2012
                      Clinical Agency Affiliations and Locations

Bryan LGH Medical Center

Lincoln, Nebraska

Creighton University Medical Center            Students must complete Exhibits A & B in addition to viewing
                                               video prior to the state date of clinical rotation. Faculty contact
Omaha, Nebraska                                contract office for video and to complete Exhibit C.
Nebraska Methodist Hospital
Omaha, Nebraska
Saint Francis Medical Center                   Adult Gerontological Acute Care NP program.
                                               Student must complete and sign Exhibit A. Faculty please see
Grand Island, Nebraska                         Exhibt B.

              Agency Name                                     Agency Requirements

99th Medical Group, Mike O’Callaghan Federal   Student must complete Trainee Agreement Addendum
Nellis Air Force Base, Nevada
Carson Tahoe Regional Healthcare
Carson City, Nevada

New Hampshire
              Agency Name                                     Agency Requirements

Catholic Medical Center
Manchester, New Hampshire
Elliot Health System                           Exhibit A: Faculty please read. Exhibit B: Student
                                               Confidentiality Agreement.
Manchester, New Hampshire
Littleton Regional Hospital
Littleton, New Hampshire
Mary Hitchcock Memorial Hospital,              Nurse Practitioner Agreement – student must hold an RN
                                               license to practice in the State of New Hampshire
Dartmouth-Hitchcock Clinic
Lebanon, New Hampshire
Speare Memorial Hospital                       Faculty, provide information regarding curriculum and clinical
                                               education goals associated with the clinical rotation. Must notify
Plymouth, New Hampshire                        agency within 1 month in advance to change student
                                               assignment. Faculty must complete a student profile from the
                                               agency to include a picture of the student (for ID purposes)
                                               specific dates of the clinical rotation.
                                               Students must maintain Health insurance coverage during
                                               clinical. Students must have had physical exam prior to
                          UNIVERSITY OF SOUTH ALABAMA
                                 COLLEGE OF NURSING
                                   November 2, 2012
                       Clinical Agency Affiliations and Locations

                                               beginning of clinical rotation.
Wentworth-Douglass Hospital                    Student must provide agency a copy of the following: 5-Panel
                                               Drug/Alcohol Screen, Background Check, Proof of Physical
Dover, New Hampshire                           within 1 year including TB, & Record of Immunizations

New Jersey
               Agency Name                                   Agency Requirements

AtlantiCare Regional Medical Center
Egg Harbor Township, New Jersey
Cooper University Hospital                     Attachments to be completed by faculty and student
Camden, New Jersey
South Jersey Hospital, Inc. (aka Bridgeton
Mental Health Unit)
Bridgeton, New Jersey

New Mexico
               Agency Name                                   Agency Requirements

27th Special Operations Medical Group          Student must sign Attachment 1 – Trainee Agreement
                                               Addendum prior to beginning clinicals.
Cannon Air Force Base, New Mexico
Presbyterian Healthcare Services (to include   Student must sign and complete Exhibit B prior to beginning
Presbyterian Rust Medical Center and Lincoln
County Medical Center)
Albuquerque, New Mexico
Public Health Division of the New Mexico
Department of Health
Santa Fe, New Mexico
University of New Mexico Hospital              Agency requires student(s) be complete drug screening within 6
                                               months before beginning clinicals at UNMH. Faculty to complete
Albuquerque, New Mexico                        Exhibit A. Student(s) must provide UNMH and USA CON with
                                               copy of certificate of insurance as proof of their property damage
VA Medical Center of New Mexico                BSN and MSN

Albuquerque, New Mexico

North Carolina
             Agency Name                                   Agency Requirements

Brynn Marr Behavioral Healthcare System
                           UNIVERSITY OF SOUTH ALABAMA
                                  COLLEGE OF NURSING
                                    November 2, 2012
                        Clinical Agency Affiliations and Locations

Jacksonville, North Carolina
Catawba Valley Medical Center
Hickory, NC
CaroMont Health
Gastonia, North Carolina
Charlotte Mecklenburg Hospital Authority
d/b/a Carolinas HealthCare System
Charlotte, North Carolina
Cumberland County Hospital System, Inc.        Students must complete Appendix 1 prior to beginning clinicals.
                                               Faculty, please contact CON contract office for appendix.
d/b/a Cape Fear Valley Health System
Fayetteville, North Carolina
Duke University Health System, Inc.            Student will not be permitted on-site without documentation verifying
                                               Criminal Background Check and Immunization status & signed
Durham, North Carolina                         Confidentiality Statement on file. Student will need to complete
                                               Compliance and Safety Training and have current CPR certificate.
                                               Faculty should contact Contract person at CON regarding student’s
First Health of the Carolinas                  Faculty and Students please read the Policy and Procedures.
                                               Available from the Contracts Office. Faculty must complete the
                                               Clinical Assessment Check list.
Pinehurst, North Carolina

Gaston Health Care, Inc. d/b/a CaroMont        Only for Acute Care Nurse Practitioner students.
Gastonia, North Carolina
Gaston Public Health Department                For Undergraduate and Graduate Students.

Gastonia, North Carolina

Hilton Head Hospital                           Student must complete Exhibit A, B, and C. Exhibit C must be signed
                                               by the Dean.
Hilton Head, North Carolina
MedWest Healthcare System to include:          Students must review the online Academic Affiliate Clinical Rotation
                                               Manual and complete required documents 4 weeks in advance of the
MedWest Haywood, MedWest Harris, and           start of the clinical experience. (Appendices A-E must be completed).
Medwest Swain                        

                                               Faculty: please email contracts department for attachment.
Clyde, North Carolina

Moses Cone Health System                       A negative Twelve Panel Urine Drug Screen report test from a
                                               National Institute of Drug Abuse (NIDA) approved laboratory on file
Greensboro, North Carolina                     prior to the first assignment/student experience at MCHS with USA
Naval Health Clinic
Cherry Point, North Carolina
Novant Health Hospitals                        Students please request Attachment C (from faculty)prior to starting
North Carolina

Triad Region: Forsyth Memorial Hospital,
Foundation Health Systems, Carolina Medicorp
Enterprises, Forsyth Medical Group,
Community General Health Partners, Medical
Park Hospital.
                            UNIVERSITY OF SOUTH ALABAMA
                                   COLLEGE OF NURSING
                                     November 2, 2012
                         Clinical Agency Affiliations and Locations

Southern Piedmont Region: Presbyterian
Orthopaedic Hospital, Presbyterian Medical
Matthews, Presbyterian Hospital, Presbyterian
Regional Healthcare, Presbyterian Hospital
Orange County Health Department
Hillsborough, North Carolina
University of North Carolina Hospital (UNC      Faculty must provide number of student(s), course objectives, and
                                                responsible faculty member from USA to UNC’s program
Hospital)                                       coordinator. Faculty and Student please read Appendix A. Students
                                                must read and sign Appendix B and C prior to beginning clinicals.
Chapel Hill, North Carolina                     12 panel drug screen required.

W.G. (Bill) Hefner VA Medical Center            Faculty must complete the “Clinical Education Form and Clinical
                                                Instructor Form ” prior to the student beginning clinicals
Salisbury, NC
VA Medical Center of Asheville, NC              Advanced Practice Nursing

Asheville, North Carolina
VA Medical Center of Fayetteville               Family Psychiatric NP students only

Fayetteville, North Carolina
Wake Forest University Baptist Medical          For Clinical Faculty and Students additional on-site
                                                requirements may include participating in orientation, on site
Center (North Carolina Baptist Hospital)        HIPAA and other training, submission to a TB test, submission
                                                of a criminal background check, a 10 panel drug screen, and
Winston-Salem, North Carolina                   proof of a seasonal flu vaccine.

Womack Army Medical Center                      For MSN students only – No more than two (2) trainees annually

Ft. Bragg, North Carolina

North Dakota
                Agency Name                                       Agency Requirements

Medcenter One, Inc.                                 Preventive health requirement form has to be completed on
                                                    student. Student must complete Net Learning System. Faculty
Bismarck, North Dakota                              should contact Contract person at CON.
Altru Health Systems (renewing)                     Students and Faculty: Request to see Addendum under
                                                    Agreement Attachments.
Grand Forks, North Dakota

                Agency Name                                       Agency Requirements
                          UNIVERSITY OF SOUTH ALABAMA
                                 COLLEGE OF NURSING
                                   November 2, 2012
                       Clinical Agency Affiliations and Locations

Ohio State University Medical Center             Students please request information about Ohio Board of
                                                 Nursing Requirements(Attachment A)
Columbus, Ohio
Ohio State University- on behalf of The Arthur   Faculty members please see me regarding attachment A prior to
                                                 student’s clinical experience
James Cancer Hospital and Richard J. Solove
Research Institute
Columbus, Ohio
Summa Health System Hospitals
Akron, Ohio
The Toledo Hospital
Toledo, Ohio
VA Medical Center of Dayton, OH                  Master in Nursing

Dayton, Ohio

               Agency Name                                      Agency Requirements

AHS Oklahoma Health System, LLP
Tulsa, Oklahoma
Alegent Health
Omaha, Nebraska
INTEGRIS Health, Inc.                            Students must complete Exhibit A, Student Confidentiality
Oklahoma City, Oklahoma
Jane Phillips Health Corporation
Bartlesville, Oklahoma
Oklahoma Area Indian Service (Lawton Indian

Lawton, Oklahoma

Oklahoma City Indian Clinic                      Students must provide agency with a copy of their current
                                                 criminal record check and shot records to include: proof of TB
Oklahoma City, Oklahoma                          skin test (within 1 year), proof of rubella/rubeola, proof of
                                                 chickenpox (either immunization, titer, or signed statement of
                                                 past infection, and proof of Hep B immunization or declination
Oklahoma State Department of Health              Students must complete HIPAA Training for Nursing Students at
                                        Please see clinical faculty
Oklahoma City, Oklahoma                          for detailed instructions. Once the students complete the HIPAA
                                                 online training, they will be able to print out a certificate.
OU Medical Center                                Students are required to submit flu vaccinations information and
                                                 additional paperwork prior to clinicals to Steven Gifford via fax to
Oklahoma City, Oklahoma (OU Medical
                                                 (405) 271-7344. Students must review the orientation
Center, The Children’s Hospital at OU            information online prior to beginning clinicals. (see website
Medical, and OU Medical Center Edmond)           below) Faculty should contact Contract person at CON with any
                                                 questions. Students must adhere to agency’s Flu Vaccine
                                                 program –see attachment.

                         UNIVERSITY OF SOUTH ALABAMA
                                COLLEGE OF NURSING
                                  November 2, 2012
                      Clinical Agency Affiliations and Locations

                                              Please see Vonda Epperly at site for further orientation
                                              information prior to starting clinicals.
OU Physicians                                 Student must complete Attachment A, “Affiliation Confidentiality
                                              Agreement,” prior to beginning clinicals.
Oklahoma City, Oklahoma
Planned Parenthood of Arkansas and Eastern    Arkansas Board of Nursing must be notified by faculty of
                                              student name, licenses number, preceptor information, clinical
Oklahoma, Inc.                                site, course of enrollment and number of clinical hours.
Tulsa, Oklahoma
St. Francis Health System, Inc.               Graduate advisor to confirm background check w/ agency and
                                              faculty to contact agency prior to students beginning clinicals.
Tulsa, Oklahoma
St. John Medical Center
Tulsa, Oklahoma
Tinker Air Force Base(72nd Medical Group)     FNP students in the pediatric population utilizing the Pediatric
Oklahoma City, Oklahoma

University of Oklahoma, School of Community   Students must sign the Confidentiality Agreement

Tulsa, Oklahoma
VA Medical Center–South Central OK            Master of Science, Nurse Practitioner (MS)

Oklahoma City, Oklahoma

              Agency Name                                   Agency Requirements

PeaceHealth Oregon Region (Springfield,
Eugene, Creswell and Cottage Grove,
Providence Health and Services                Background check must be dated less than two years prior to
                                              practicum. Any adverse results must be shared with the
(Oregon Region)                               hospital. Background check verification letter required. HIPAA
Portland, Oregon                              – DVD and brochure reviews required.
VA Healthcare System of Roseburg              MSN, Post-Masters Advanced Psychiatric-Mental Health
                                              (NP/CNS) programs
Roseburg, Oregon
VA Medical Center of Portland, OR             Gerontological/Adult Psychiatric, Masters

Portland, Oregon

              Agency Name                                   Agency Requirements

Take Care Health Systems, LLC                 NP STUDENTS
                            UNIVERSITY OF SOUTH ALABAMA
                                   COLLEGE OF NURSING
                                     November 2, 2012
                         Clinical Agency Affiliations and Locations

Conshohocken, Pennsylvania                       Faculty may need to send clinical program letter to agency,
                                                 outline available from Contract Office.

                                                 Students: Name tags must be clearly visible and worn at all
                                                 times while at the facility. Student must notify agency prior to
                                                 scheduled start time if the student will be absent from scheduled
                                                 participation in the Clinical Program.

VA Stars and Stripes Healthcare Network
Lebanon, Pennsylvania
Saint Luke’s Hospital of Bethlehem (to include   Faculty:
                                                 Faculty and Agency will agree to the number of students, their
locations at: 801 Ostrum St. Bethlehem, 1736
                                                 schedule and dates of admission at least (6) six weeks prior the
Hamilton Blvd. Allentown, PA, 1872 Riverside     date of admission. The specific days and hours of the student’s
Circle, Easton, PA, St. Luke’s Quakertown        activities at St. Luke’s Health System will be mutually agreed
Hospital, St. Luke’s Miners Memorial Hospital,   upon by both parties.
                                                 Upon request Faculty will complete the Request for Clinical
Visiting Nurse’s Assoc. of St. Luke’s, Home
                                                 Education Affiliation Agreement, in the form Exhibit 1 available
Health/Hospice, Inc. and St. Luke’s Physician    through the Contracts Office.
Group, Inc.)                                     Students:
                                                 Background Check:
                                                 Student must complete and submit to agency the following:
                                                          a. Student registration form.
                                                          b. Student statement of responsibility.
                                                          c. Student must maintain and provide evidence of
                                                               current CPR certification for the duration of
                                                               clinicals .
                                                          d. Students shall be responsible for maintaining
                                                               health insurance coverage while in clinicals.
                                                 Drug Screen:
                                                 Must have a clear 5 panel urine drug screen test administred by
                                                 an HHS-certified lab to include: 1.amphetaphines, 2.cocaine,
                                                 3.cannabinoids, 4.opiates (including morphine, codeine,
                                                 hydromorphone, and hydrocodone) and 5. phencyclidine. Drug
                                                 Screen Test: Drug Test must be administered no
                                                 earlier than 30 days prior to the date of beginning
                                                 Such other health related information and/or testing as may be
                                                 requested by St. Luke’s Health System from time to time.
                                                  Faculty and Students: * Administration of such test shall be
                                                 required prior to student's first assignment at PROVIDER.If a
                                                 student maintains continuous enrollment at SCHOOL and
                                                 participates in a subsequent rotation at PROVIDER, and
                                                 SCHOOL provides a written statement to PROVIDER prior
                                                 to such subsequent rotation that it has no reason to believe
                                                 that the student has not continued to be drug- free, safe
                                                 and qualified for the clinical experience under this
                                                 Agreement, then such test will not be required for the
                                                 subsequent rotation. If no such statement is provided by
                                                 SCHOOL, such test will be required prior to the subsequent
                          UNIVERSITY OF SOUTH ALABAMA
                                 COLLEGE OF NURSING
                                   November 2, 2012
                       Clinical Agency Affiliations and Locations


                                                Health Requirements: No active Tuberculosis, as evidenced by
                                                two tuberculin skin tests showing either (a) a negative result,
                                                (demonstrated by either the last two consecutive annual TB skin
                                                tests dated within two (2) years of the date of assignment at St.
                                                Luke's OR two step TB testing - two tests dated within one (l)
                                                year of date of assignment at St. Luke's) or (b) if a positive
                                                result, additional completion of a TB symptom questionnaire
                                                AND negative chest x-ray or BAMT
                                                Blood Assay Mycobacterium Tuberculosis test done no earlier
                                                than three (3) years prior to the date of assignment at the
                                                PROVIDER. History of BCG administration without TB testing is
                                                NOT acceptable.

Rhode Island

               Agency Name                                    Agency Requirements

Women & Infants Hospital
Providence, Rhode Island

South Carolina
               Agency Name                                    Agency Requirements

Aiken Barnwell MHC (South Carolina              Students must provide proof of vaccines prior to beginning
Department of Mental Health)

Columbia Area Mental Health Center
Columbia, South Carolina
Eau Claire Cooperative Health Centers, Inc.
(Includes Waverly Family Practice)
Columbia, South Carolina
Greenville Hospital University Medical Center   Students must complete Verification Form, Appendix C, and
                                                Appendix D prior to clinicals. All rotations must be approved
                          UNIVERSITY OF SOUTH ALABAMA
                                 COLLEGE OF NURSING
                                   November 2, 2012
                       Clinical Agency Affiliations and Locations

Greenville, South Carolina (renewing)         through “Students Services Dept.” 4 months prior to start date.
Lexington County Health Services District     Faculty must be licensed, registered or certified by the state
                                              of South Carolina.
West Columbia, South Carolina (please ask     Faculty: Submit a final written roster of names of the
contracts dept. for a complete list of        participating students one week prior to the beginning of the
agency’s included under contract)
                                              Criminal background check must be done
                                              within 90 days of student’s first rotation at
                                              facility. Faculty: please notify Mary Meyer to
                                              Please read, student list of requirements (available from
                                              Contracts Office).
Medical University Hospital Authority
Medical University of South Carolina
Charleston, South Carolina
Moncrief Army Community Hospital              Family Psychiatric Nurse Practitioner students.
Fort Jackson, SC
Roper St. Francis Healthcare                  The student must show written documentation of the
Charleston, South Carolina
                                              Hepatitis B vaccination or refussal

                                              Negative Tuberculin Skin Test (TST) must have been
                                              tested within the last 12 months or documentation of
                                              negative two step TST.

                                              Student's immunity history for varicella, rubella, and
                                              rubeola. ( If previous rubella is not in the history, and titer
                                              is negative, a rubella vaccine shall be required.

                                              Influenza vaccine within the past twelve months or

Sisters of Charity Providence Hospital        Students should contact Ms. Soderstrom at agency for
                                              additional paperwork requirements prior to clinicals.
Columbia, South Carolina
South Carolina Dept. Health and Environment   Student must sign Attachment 1

Columbia, South Carolina
South Carolina Department of Mental Health
(Division of Inpatient Services)
Columbia, South Carolina
University of South Carolina
Columbia, South Carolina
VA Medical Center (Wm. Jennings Bryan         Faculty-Educational Institution Verification Letter must be signed
                                              and sent from Dr. Rhodes.
Columbia, South Carolina

South Dakota
                          UNIVERSITY OF SOUTH ALABAMA
                                 COLLEGE OF NURSING
                                   November 2, 2012
                       Clinical Agency Affiliations and Locations

                 Agency Name                                   Agency Requirements

Sanford Health                                   Students must review and complete the Sanford Health Orient
                                                 ation Packet, please note the directions for sending the forms.
Sioux Falls, South Dakota                        They can be faxed to 605-312-9837 or scanned/emailed to:
                                                 Faculty must complete the Faculty Verification form and provide
                                                 objectives and the final preceptor evaluation form no later than 2
                                                 weeks before clinical experience begins. Please ask contract
                                                 office for info sheet from Sanford.

                 Agency Name                                   Agency Requirements

Chattanooga-Hamilton County Hospital
Authority d/b/a Erlanger Health System
Chattanooga, Tennessee
Covenant Health                                  Completion of Exhibits A & B prior to student beginning clinicals
                                                 Faculty must verify that the student has received the
Knoxville, Tennessee                             required flu vaccination and supply documentation as such
                                                 to the facility.
Dyersburg Regional Medical Center
Dyersburg, Tennessee
HCA Health Services of Tennessee, d/b/a
Centennial Medical Center
Nashville, Tennessee
Jackson-Madison County General Hospital,
West TN Healthcare
Jackson, Tennessee
Matthew Walker Comprehensive Health
Nashville, Tennessee
Maury Regional Hospital d/b/a Maury Regional
Medical Center
Columbia, Tennessee
Mercy Health System, Inc. (formerly St. Mary’s   Student must have 30 day advance approval from agency.

Health System)
Knoxville, Tennessee
Methodist Healthcare-Memphis Hospitals           Students: Exhibit A must be completed prior to starting clinicals.
                                                 Please see course coordinator regarding details.
Memphis, Tennessee                               Students must complete a ten-panel drug screen from an
                                                 independent provider within 30 days of the commencement date
                                                 of the clinical experience as well as a criminal background check
                                                 conducted within the preceding 12 months prior to clinical
Methodist LeBonheur Healthcare                   Students must sign Exhibit A (Hepatitis Statement) prior to
                                                 beginning clinicals. Students must show documentation of flu
Memphis, Tennessee                               vaccine. As of January 1, 2013-Students must have a
                                                 background check and 10-panel drug screen completed
                                                 through either Verified Credentials or Certified Background.
                                                 No other vendor will be accepted.
                          UNIVERSITY OF SOUTH ALABAMA
                                 COLLEGE OF NURSING
                                   November 2, 2012
                       Clinical Agency Affiliations and Locations

Regional Medical Center at Memphis (Shelby     Faculty must confirm health status of students, provide written
                                               student/faculty (if applicable) evaluations of each clinical
County Healthcare Corp.)                       rotation, and provide a copy of the curriculum, clinical objectives
                                               and students’ skill and competency levels.

Tri Star Skyline Medical Center & Tri Star     Students shall pass a medical examination acceptable to
                                               Hospital prior to their beginning their clinical program and at
Skyline Madison Campus                         least once a year or as required by Tennessee law.

Nashville, Tennessee                           Students will present their health records on the first day of
                                               clinicals, to include (TB skin test with in the past 12 months or
                                               documentation as a previous positive reactor, Proof of Rubella
                                               and Rebeola immunity or 2 doses of MMR, Varicella immunity
                                               by positive history of chickenpox or proof of immunization, Proof
                                               of Heatitis B immunization or declination of vaccine, if patient
                                               contact is anticipated.

                                               Student will need to provide proof of background check. Please
                                               find exhibits A & B to be completed by the student

St. Mary’s Health System (now owned by Mercy   Student must have 30 day advance approval from agency.

Health System, Inc.)
Knoxville, Tennessee
Southeastern Emergency Physicians, Inc.
Knoxville, Tennessee
The Little Clinic                              Faculty please complete Exhibit 1.8 (number of students and
Brentwood, Tennessee
University Health System, Inc.                 Student must complete Exhibits A & B and Attachment 1 prior to
                                               beginning clinicals
Knoxville, Tennessee
Vanderbilt University (Hospital, Clinic,       Clinical rotation criteria and background investigation.

Children’s Hospital)
Nashville, Tennessee
Tennessee Valley Healthcare System             Master of Science

Nashville, Tennessee
VA Medical Center of Memphis, TN
Memphis, Tennessee
Veterans Affairs Outpatient Clinic             Graduate Program,
                                               Master of Science in Nursing
Chattanooga, Tennessee

                Agency Name                                   Agency Requirements
                                UNIVERSITY OF SOUTH ALABAMA
                                       COLLEGE OF NURSING
                                         November 2, 2012
                             Clinical Agency Affiliations and Locations

Baptist Health System                                       *Student must complete Exhibit A & B before starting clinicals.
                                                            (See Faculty for information)
San Antonio, Texas                                          *Students are required to have flu and HINI vaccines by
                                                            December 15, 2009 and the Proof of Vaccination form must be
                                                            completed prior to clinicals. (See faculty member regarding
Carl R. Darnall Army Medical Center
Fort Hood, Texas
Children’s Medical Center of Dallas                         Master’s Degree in Nursing
Dallas, Texas
Cook Children’s Medical Center (to include the              Student must complete Exhibits A&B prior to beginning clinicals.
Physician Network)
Fort Worth, Texas
Dallas County Hospital District d/b/a Parkland              Nurse Practitioner students only. Faculty: Please ask Contract
                                                            Office for the following forms, all must be typed and completed
Health & Hospital System                                    entirely and may be faxed or scanned to Kim at 214-590-6947
Dallas, Texas                                     
                                                            Clinical Request Form-to request any rotations at Parkland.
                                                            Verification Letter- document states that the students listed all
                                                            meet the requirements under the current contract on file.
                                                            Students MUST have background check and 10
                                                            panel drug screen within 30 days of beginning
                                                            Students must complete to following-type and filled out entirely.
                                                            Badge Request-please fax or scan to Kim at 214-590-6947 or
Darnall Army Community Hospital                             Program leads to Masters of Science in Nursing in
                                                            Community/Public Health Nursing
Fort Hood, Texas
Driscoll Children’s Hospital                                Students must complete Exhibits A & B prior to beginning
                                                            clinicals. CON must complete Exhibit C on behalf of student.
Corpus Christi, Texas                                       Effective Flu Season 2011, the Influenza Vaccine is
                                                            MANDATORY for all program participants (instructors and
                                                            students). Exhibit C must be completed prior to beginning
El Paso Children’s Hospital                                 Faculty and Students please thoroughly read attachment-
                                                            Addendums A-G (to include background check,
                                                            immunizations, and code of conduct requirements from
El Paso Texas                                               agency)

                                                            Student must attend agency’s orientation.

                                                            Faculty must furnish student assignments (date, time of clinical

El Paso County Hospital District, d/b/a R.E.                Students must complete agency’s Non-Disclosure Agreement
                                                            and attend orientation provided by the hospital prior to beginning
Thomason General Hospital                                   clinicals.
El Paso, Texas
HCA North Texas (includes Denton Regional Medical           Students must complete Exhibit A (Statement of Responsibility)
                                                            and Exhibit B (Confidentiality Statement) prior to beginning
Center, Green Oaks Psychiatric Hospital, Las Colinas
                                                            clinical rotation. Faculty please send completed Attestation Form
Medical Center, Medical Center of Arlington, Medical        to the hospital in which your student is using as a clinical site.
Center of Lewisville, Medical Center of McKinney,
Medical Center of Plano, Medical City Dallas Hospital,
North Hills Hospital, and/or Plaza Medical Center of Fort
Irving, Texas
Lone Star Circle of Care
Georgetown, Texas
                          UNIVERSITY OF SOUTH ALABAMA
                                 COLLEGE OF NURSING
                                   November 2, 2012
                       Clinical Agency Affiliations and Locations

Memorial Hermann Northwest Hospital              Students must complete Exhibit B prior to beginning clinicals.
Houston, Texas
Memorial Hermann-Texas Medical Center and        Students please see Mary Margaret Evans@ site for required
                                                 paperwork prior to clinicals. Also Student Faculty requirements
Children’s Memorial Hermann Hospital             in file. Complete Exhibit E.
Houston, Texas
Memorial Hermann The Woodlands Hospital          Students must complete Exhibit B prior to beginning clinicals.

The Woodlands, Texas
Methodist Healthcare System of San Antonio,      Non-MHS employees must go to MHS HIPAA and ethics
                                                 session prior to beginning clinicals.
Ltd., L.L.P.                                     *Employment verification required (for 7 years)
San Antonio, Texas
Northwest Texas Healthcare System
Amarillo, Texas
Planned Parenthood of Houston and
Southeast Texas, Inc.
Houston, Texas
Presbyterian Hospital of Plano (renewing)        Course Coordinators-please complete attachments

Plano, Texas
R.E. Thomason General Hospital (El Paso          Students must complete agency’s Non-Disclosure Agreement
                                                 and attend orientation provided by the hospital prior to beginning
County Hospital District)                        clinicals.
El Paso, Texas
ReHab Care
Austin, TX or St. Louis, MO
Seton Healthcare d/b/a Seton Healthcare
Network, Austin, Texas (to include but not
limited to Seton Medical Center Austin, Seton
Northwest Hospital, University Medical Center
at Brackenridge Hospital, Seton Shoal Creek
Hospital, Seton Edgar B. Davis Hospital, Dell
Children’s Medical Center, Seton Southwest
Hospital, Seton Medical Center Williamson,
Round Rock, Seton Medical Center Hays.
TCH Pediatric Associates, Inc. d/b/a Texas
Children’s Pediatric Associates
Houston, Texas
Texas Tech University Health Sciences            Faculty must complete Faculty of Record/Coordinator
                                                 Credentialing form and Pre-Clinical Clearance Form prior to
Center, Paul L. Foster School of Medicine,       students beginning clinicals. Faculty please contact Alicia
Department of Pediatrics (Renewing)              Gacharna at (915) 545-6921 for forms.
El Paso, Texas
The University of Texas Medical Branch at        Correctional Managed Care department and Ob-Gyn
                                                 Department (Regional Maternal & Child Health Programs)
Galveston, Texas
University Medical Center of El Paso (formerly   Students please see agency contract specialist regarding
                                                 special instructions/attachments required before clinicals
                          UNIVERSITY OF SOUTH ALABAMA
                                 COLLEGE OF NURSING
                                   November 2, 2012
                       Clinical Agency Affiliations and Locations

R.E. Thomason General Hospital)
El Paso, Texas
VA Medical Center of Michael DeBakey
Houston, Texas
Veterans Affairs North Texas Medical Center   Advanced Geropsych Assessment Older Adults Practicum RN-
Dallas, Texas                                 Master of Science in Nursing
William Beaumont Army Medical Center          Family Nurse Practitioner students
                                              (Agreement applies to only one trainee at a time).
El Paso, Texas

               Agency Name                                 Agency Requirements

Brigham City Community Hospital (renewing)    Students must complete Exhibit A and B. Faculty must complete
                                              Exhibit C on behalf of the student.
Brigham City, Utah
Central Utah Clinic
Provo, Utah
IHC Health Services, Inc. (Intermountain
Salt Lake City, Utah
University of Utah Hospitals and Clinics      The student needs to purchase their own general
                                              liability insurance with the amounts being
                                              $1000,000/$3,000,000. Also, the student will be
Salt Lake City, Utah
                                              responsible for health insurance/ or worker's

                                              Faculty: At least four weeks prior to the beginning date
                                              the agency must be sent the name of each student and
                                              the program description to the University of Utah
                                              Hospitals and Clinics.

               Agency Name                                 Agency Requirements

Fletcher Allen Health Care
Burlington, Vermont

                            UNIVERSITY OF SOUTH ALABAMA
                                   COLLEGE OF NURSING
                                     November 2, 2012
                         Clinical Agency Affiliations and Locations

                    Agency Name                               Agency Requirements

Chesapeake Hospital Authority d/b/a             Faculty, please send a copy of the evaluation that the student
                                                completes to the facility at:
Chesapeake Regional Medical Center
Chesapeake, Virginia                            757-312-6829 Fax, or

Kenner Army Health Clinic (includes Wilkerson
Pediatric Clinic)
Fort Lee, Virginia
Medicorp Health System (includes Mary
Washington Healthcare)
Fredericksburg, Virginia
Naval Medical Center                            Nurse Practitioner students and Clinical Nurse educator
                                                students—See faculty first
Portsmouth, Virginia                            ***Faculty must contact the agency and complete the
                                                agency’s request form prior to students starting clinicals.
                                                Students please see agency official regarding Parking
Sentara Healthcare System (includes: Sentara    Students must purchase additional professional liability
                                                insurance (outside of USA) with limits of $1 million/occurrence
Bayside Hospital, Sentara Leigh Hospital,       and $3 million aggregate in order to intern at this site, since
Sentara Norfolk General Hospital, Sentara       Virginia law requires higher limits that the University offers.
Careplex Hospital, Sentara Virginia Beach
General Hospital, Sentara Williamsburg
Regional Medical Center, & Sentara Louise
Obici Memorial Hospital)
Chesapeake, Virginia
University of Virginia Health System            Nurse Practitioner Agreement

Charlottesville, Virginia

Valley Health System                            Agency requires a 10-panel drug screen; student must maintain
                                                professional liability insurance in the amounts of $2
Winchester, Virginia                            million/occurrence and $6 million aggregate; student must
                                                complete exhibits prior to beginning clinicals.
Virginia Commonwealth University Health
System (Medical College of Virginia)
Richmond, Virginia
Virginia Department of Health (Prince William   Faculty must notify Department at least 60 days in advance:
                                                number of students and beginning and ending dates for clinicals.
Health District, Portsmouth Department of       Submit in writing to the Department at least 30 days in advance
Health)                                         of mutually agreed upon planned experience.
Richmond, Virginia                              Student will maintain $2,000,000 in general liability
                                                coverage and provide evidence of said coverage.

                    Agency Name                               Agency Requirements

DSHS Mental Health Division (Western State
                           UNIVERSITY OF SOUTH ALABAMA
                                  COLLEGE OF NURSING
                                    November 2, 2012
                        Clinical Agency Affiliations and Locations

Olympia, Washington
Shriners Hospitals for Children              * Agreement begins effective term August 22, 2011.

Spokane, Washington
VA Puget Sound Health Care System
Seattle, Washington
Western State Hospital—DSHS Mental Health
Olympia, Washington

Washington D.C
               Agency Name                                 Agency Requirements

Children’s Hospital
Washington, D.C.
Georgetown University Hospital               The following items must be completed prior to student
                                             beginning clinicals: Faculty provides syllabus to CON contract
Washington, D.C.                             office as Attachment A, Dean must sign Attachment B, and
                                             student signs Attachment D.

West Virginia
               Agency Name                                 Agency Requirements

VA Medical Center of Huntington
Huntington, West Virginia

               Agency Name                                 Agency Requirements

Affinity Health System                       Students must complete Exhibit B and review Exhibit C
Menasha, Wisconsin
Aurora Medical Group, Inc.                   To include all of AHC facilities.
Milwaukee, Wisconsin
Bellin Memorial Hospital, Inc.               Students must complete agency’s application, Wisconsin
                                             Background Information Disclosure form, return agency’s HIPAA
Green Bay, Wisconsin                         confidentiality agreement, self-study orientation packet and test
                           UNIVERSITY OF SOUTH ALABAMA
                                  COLLEGE OF NURSING
                                    November 2, 2012
                        Clinical Agency Affiliations and Locations

                                                  must be completed prior to start of rotation. Contact is Beth
                                                  Markon: (920) 433-7858
Gundersen Lutheran – Internal Medicine
La Crosse, Wisconsin
Mercy Health System
Janesville, Wisconsin
Meriter Health Services, Inc.                     USA Faculty must notify Meriter Hospital Medical Affairs Health
                                                  Services and the Family Psychiatric Mental Health Practitioner
                                                  in advance with participating student names and affiliation dates.
Madison, Wisconsin                                Students must check in with Medical Affairs for a 10-minute
                                                  orientation on the first day, or prior to, the start of clinical

St. Vincent Hospital of the Hospital Sisters of   Agency requires letter of good standing and verification of
                                                  competency in sterile technique training for each student.
the Third Order of St. Francis and St. Mary’s
Hospital Medical Center of Green Bay, Inc.

Green Bay, Wisconsin
Wheaton Franciscan Healthcare-Southeast           Faculty and Students, please see attachment with listed
                                                  agency requirements.
Wisconsin, Inc.

Milwaukee, Wisconsin

William S. Middleton Memorial Veterans

Madison, Wisoncsin

Zablocki VA Medical Center
Milwaukee, Wisconsin

                Agency Name                                     Agency Requirements

Sheridan VAMC                                     Faculty must send a Program Letter to Ms. Beverly Bernard at
                                        , letter must identify faculty, including
                                                  VA employees, who will teach, supervise, and evaluate trainee
Sheridan, Wyoming                                 performance; outline educational objectives; specify periods and
                                                  clinical area of assignments.

VA Medical Center of Cheyenne                     Nursing/Nurse Practitioner/MS

Cheyenne, WY
                         UNIVERSITY OF SOUTH ALABAMA
                                COLLEGE OF NURSING
                                  November 2, 2012
                      Clinical Agency Affiliations and Locations

                         INTERNATIONAL AGENCIES
              Agency Name                                  Agency Requirements

Landstuhl Regional Medical Center
U.S. Medical Department Activity Bavaria,   Trainees must have an interest in serving the US military as
                                            either a DA civilian or on active duty. The rotation will expose
U.S. Army Health Clinic Vilseck             the applicant to military medicine during the clinical rotation. The
                                            trainee will be asked to speak to an Army medicine recruiter.
                                            This conversation or rotation will not obligate the trainee to any
                                            military medicine service.

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