Student Instructor Documentation Checklist

Influenza Vaccination

I certify the student(s) assigned to all Virtua sites during December 1st-March 30th have received the influenza vaccine and have documentation on file for each student available for review upon request.

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Student Profile

Undergraduate Pre-Licensure Student Graduate

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Academic Organization

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Other

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

Student

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Virtua Employee

No Yes

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No Yes

Program of Study

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Other

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Instructor Name/Unit Name

Please check next to each item that has been completed according to Virtua’s placement

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

Certificate of Liability

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

I certify that all the above information is correct

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Phone Number

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Email Address

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Please only click the “Submit” button once. This form may take 1 to 2 minutes to process.

Please contact the academic affiliate coordinator for assistance. Thank you!

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Student/Instructor Documentation Checklist