Miami Hospital Discharge Forms by ojj19060

VIEWS: 388 PAGES: 3

Miami Hospital Discharge Forms document sample

More Info
									                                        MIAMI CHILDREN'S HOSPITAL
                              Nursing, Practicum Students and Intern Information

Miami Children's Hospital is a private, not for profit institution which provides for the health care needs of children from
birth through 21 years of age. The Hospital was established in March, 1950 as Variety Children's Hospital. It is a 268
bed facility, including Out Patient Services, Wellness and Specialty Clinics, Medical Arts Building and a Research
Center.

INTERNS & PRACTICUM STUDENTS include any person under the guidance of certified and/or licensed professional
within a technical or professional field who is working towards a career in that area. The experience here is a required
part of the criteria for completion of your school program or certification.

Student personnel information will be processed through and maintained by the Community & Volunteer Resources
Department for documentation purposes.

You must provide documentation of:
PPD (Tuberculosis Test) must be less than one year old.
MMR (Measles Rubella Vaccine)
Chicken Pox Titer

The following information will be provided by your education institution to the Education & Professional
Development Department:

*Documentation from school that you are aware of universal precautions.
Contract with educational institution
Proof of Liability Insurance
Program Objectives from educational institution
Instructor CV/Resume, contact phone number
Proof of instructor's current CPR Certification if applicable
Proof of instructors licensure if appropriate

*film can be seen in Community & volunteer Resources Department

ORIENTATION is provided by the Community & Volunteer Resources Department and the department the
practicum/internship experience will take place.

SCHEDULES are coordinated with the department the practicum/internship will take place in.

SIGN IN you must sign in your name, your badge number, time of arrival, and department at the Information Desk when
you arrive and sign out the time of your departure.

Documentation of your hours are available upon request from the Community & Volunteer Resources Department after
your Identification has been returned.

DRESS CODE must comply with Miami Children's Hospital's employee dress code and the dress code of the
department the practicum/internship takes place in. A Hospital Picture Identification Badge will be given to you by the
Community & Volunteer Resources Department and must be worn at all times. When you have completed your
practicum/internship you must return your Identification Badge.

APPLICATION PROCEDURE: Please complete the enclosed application and return it with all other required
application material to a minimum of one week prior to your rotation date:
                                          Miami Children's Hospital
                                          Community & Volunteer Resources Department
                                          3100 SW 62 Ave
                                          Miami, Fl 33155

We appreciate your interest in Miami Children's Hospital.
                        Practicum Student, Nursing Students
                                & Intern Application


NAME:                                                              PHONE:

HOME ADDRESS:

CITY:                                   STATE:                     ZIP CODE:

DATE OF BIRTH:                   SOCIAL SECURITY NO:

SCHOOL:                          MAJOR:                            SUPERVISING PROFESSOR/TEACHER

SCHOOL PHONE:                    PRACTIUM/INERNSHIP COMPLETION DATE:

EMERGENCY CONTACT:               RELATION:                          PHONE: (DAY & EVENING)

FAMILY PHYSICIAN:                                                   PHONE:

Have you ever been convicted or Adjudicated Guilty, Adjudication Withheld, including Nolo Contendere (No
Contest) for an offense other than a minor traffic violation? **
**[ ]YES [ ]NO IF YES PLEASE EXPLAIN.




SIGNATURE:                                                          DATE:

This hospital fully complies with the Age Discrimination in Employment Act of 1968 and
the Civil Rights Act of 1964 which prohibits employment discrimination based on race,
color, creed, sex, age, national origin, physical disability of veteran status.

** A Criminal Conviction record search is made of all prospective volunteers of the
hospital. A conviction record is not necessarily a bar to employment; factors such as age
at the time of the offense, seriousness and nature of the violation and rehabilitation will be
taken into account. However, concealment of any conviction on this application shall be
cause for discharge whenever discovered.

forms\appnurs-int.doc
8/2003
                                                    HEALTH FORM
Complete this form


Name:                                                       Date Of Birth:

Address:

City:                                  State:                          Zip Code:




 HAVE YOU HAD ANY OF THE FOLLOWING?                   YES     NO     UNKNOWN
 CHICKEN POX
 RUBELLA (GERMAN MEASLES)
 MEASLES (SEVEN DAY)
 IMMUNIZED FOR:
 RUBELLA
 MEASLES

HAVE YOU EVER HAD A TUBERCULOSIS TEST? YES [ ] NO [ ]

WAS THE RESULT?             POSITIVE: [ ]               NEGATIVE: [ ]

Do you have or are you being treated for?
         Allergies                   Hearing Problems
         Asthma                      Immune Deficiency
         Chronic Cough               Skin Disorders/Rashes
         Diabetic on Insulin         Partial Blindness
         Epilepsy                    Wrist, Back or Neck Injury

List all medications you are taking:




SIGNATURE:                                      _      DATE:          _________________

								
To top