Student Documentation Checklist

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(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

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