Health Science Internship Required Permission Forms
1. Hugh Chatham Hospital
2. Novant Health
3. Wake Forest Baptist Health Center
Hugh Chatham Hospital Required Health Forms: 1. Click to view and print the HCH Student Internship PassPort. Packet. 2. Read and know the information in PowerPoint, Clinical Student Information, on pages 1-11 of the Essential Policy Review. 3. Read the Hugh Chatham Hospital Code of Conduct Print & Sign 1.) Student Certification & Agreement of Compliance form 2.) Confidentiality/Security form(2 pgs), 3.) Standard of Performance STAR form. Other Required Items to be submitted 1. Negative 2-steps TB skin test record, (At least 1 week apart. This means 2 TB test).-If no PPD within previous 2 years 2. Copy of immunization record 3 .Copy of up-to-date Influenza Vaccine (Flu Shot) 4. Criminal Background Check form (if over age of 18) 5. Drug Screen Test (if over the age of 18) 6. Covid19 immunizations (2)
2. Click on Novant Health's Non Clinical Students, to access Novant Health Student Observation web page. If link does not work google Novant Health Student Observation (non-clinical).
3. Signed confidentiality agreement 4. Signed orientation/compliance roster 5. Signed Tobacco Free Form 6. Signed Education Experience Agreement 7. Flu Vaccine- 8. Copy of Immunization Record 9. 2-Step TB/PDD test reading results (within 1 year) 10. Covid19 immunizations (2) . Criminal Background check (nationwide SS# trace) if over 18 years of age
2. Submit 2 Supplemental Forms 3. Turn-in Copy of Immunization Record to Mrs. Reavis 4. Turn-in copy of negative 2-step TB Test Results to Mrs. Reavis 5. Turn-in copy of updated flu shot, if not recorded on immunization record 6. Turn-in copy of Covid19 immunizatons
|