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Student Documentation Checklist

Student Profile:*  Undergraduate  Pre-Licensure Student  Graduate Non-Nursing  Graduate Nursing

(Academic Organization) certifies the following documents are on file for (Student) and will be made available to Virtua within 24 hours of being requested.

Please check next to each item that has been completed accorsing to Virtua's placement

Program of Study

Licensure (RNs Only)
Current New Jersey License in good standing through duration of placement at Virtua

Health Screening
History and physical with no issues noted, which would interfere with the student's ability to meet the requirements of his or her rotation at Virtua
Varicella, Rubella and Rubeola proof of immunity
Hepatitis B proof of immunity
Annual PPD with negative results
Drug Screening with negative results

Current Life Support Certification
CPR/ACLS/PALS/NALS (as appropriate)
BLS if PT/OT/SLP
Heart Saver or BLS for any other discipline (MSW, MHA, etc) rotating at Virtua Marlton

Criminal Background Check
I certify that a national criminal background check has been performed on the student(s), reflecting no issues

Influenza Vaccination
I certify the student(s) assigned to all VIRTUA sites during Oct 1st-March 30th are in compliance with VIRTUAs Influenza Policy and have documentation on file available for review upon request
Accept
Decline

Certificate of Liability
An updated copy of the certificate of liability convering professional and general liability for the student(s) has been faxed to Virtua's legal department as specified in the affiliate agreement

Name of Certifier

Phone Number

Email Address