Form Final: 7/8/08 CLINICAL PLACEMENT ATTESTATION FORM - Clinical Placement Pilot 1 of 1
Name of School: _________________________________________________________________________ Course Number: ___________________________
Name of Clinical Agency for Placement: ____________________________________________________ Name of Course:___________________________
Dates for Clinical Placement: (Start/End) _______________________________________________ Days of the Week/Shift: ___________/______________
Units for Clinical Placement: _______________________________________________________________
This form is to be completed for each clinical group of students in the agency.
Items marked with an "X" or expiration date below have a document on file at the School / Mark "N/A" if item not a requirement on the affiliation agreement.
BLS/ Month/Day of Training
Negative Profic. TB CPR Negative Drug Clinical Agency Birth for /Access ID
Student Roster - Full Name with Middle Initial Background Written & PPD/ Exp. Physical Screen and/or Orientation Computer information
and Current Contact Information (Phone/Email) Check Oral English X-Ray MMR Varicella Hep B Date Exam Waiver Scheduled Access (last 4 digits)
BLS/ Month/Day of Training
Clinical Instructor Full Name and Middle Negative Profic. TB CPR Physical Negative Drug Clinical Agency Birth for /Access ID
Initial and Contact Information Background Written & PPD/ Exp. Exam/ Screen and/or Orientation Computer information Computer
(Phone/Pager/Cell and Email) Check Oral English X-Ray MMR Varicella Hep B Date Attestation Waiver Scheduled Access (last 4 digits) Training
Course Instructor Contact Information:
Phone: Pager: Cell:
As per our affiliation agreement, the school has in place Malpractice Insurance, Worker's Compensation and has established lawful presences
in the United States for all students and faculty.
All of the above have also completed the required: HIPAA/Confidentiality; Safety and Bloodbourne Pathogen; and Cultural Diversity Training and Competency Testing
While in the clinical agency, all students and school representatives will display a Photo ID Badge.
Form Completed by: ____________________________________________ Date Completed: _____________________________________
Phone Number: Email Address:
Back-up at the School Name: _____________________________ Title:______________________ Phone:_________________________
Director/Dean Signature:____________________________________________________ Date: _____________________________________________
*4/8/09 Approved by the Standards Sub-Committee /*4/9/08 - Form endorsed by the ACE Services and Education Sub-Committee to replace the required "Attestation Letter and Student Roster."
Final Approval by the Clinical Placement Oversight Committee 5/19/08 for acceptance and use with all Pilot Partners -- Taken to ACE July/2008