1-888-VIRTUA-3 1-888-VIRTUA-3
Live Chat
My Virtua
Careers
Classes & Events
Giving
About Us
ER Wait Times

Find A Doctor
- Primary & Specialty Care
- Pediatrics
Locations
Most Viewed Locations
View All Locations
Locations Search
Services
Most Viewed Services
View All Services
Services Search

Services A-Z
A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

R

S

T

U

V

W

X

Y

Z

Adolescent Gynecology

Allergy and Immunology - Pediatric

Angioplasty

Arthritis

Arthroscopic Surgery

Balance Testing and Care

Bariatric Weight-Loss Surgery

Behavioral and Mental Health

Behavioral Health - Pediatric (CASTLE)

Bio-identical HRT

Bladder Cancer

Brain and Spine

Brain Surgery

Breast Cancer

Breast Health and Mammograms

Breast Reconstruction

Breastfeeding

Cancer Genetic Counseling and Testing

Cancer Support Services

Cancer Surgery

Cancer Treatment

Cardiac Catheterization

Cardiac Rehabilitation

Cardiology - Pediatric

Cardiovascular Health

CASTLE

Cervical Cancer

Chemotherapy

Chest Pain Care

CHOP at Virtua

Clinical Trials

Colonoscopy

Colorectal Cancer

Colorectal Surgery

Concussion/ImPACT Testing

Cosmetic Plastic Surgery

Critical Care - Pediatric (PICU)

Dentistry

Depression and Pregnancy

Dermatology

Diabetes Care

Diagnostic Imaging - Pediatric

Diet and Wellness Coaching

Ear, Nose and Throat (ENT)

Early Intervention Program

Emergency Medical Services

Emergency Medicine

Emergency Services - Pediatric

EMS Continuing Education

Endocrinology - Pediatric

Exuberan

Eye Care

Family Medicine

Female Pelvic Health

Fitness

Gastroenterology

Gastroenterology - Pediatric

Geriatric Care Management

Gestational Diabetes

Gynecologic Oncology

Hand Surgery and Rehabilitation

Healthy Eating

Heart Disease And Pregnancy

High-Risk Pregnancy Care

Hip Preservation

Hip Replacement

Home Health Care

Hospice Care

Hyperbaric Oxygen Therapy

Immunotherapy

Infertility

Internal Medicine

Joint Replacement Institute

Kidney Cancer

Knee Replacement

Lab Services

LifeCare

Long-Term Care and Rehabilitation

Lung Cancer

Lung Wellness Program

Lymphoma

Maternity

Medical Nutrition Therapy

Medical Oncology

Medical Weight Loss

Menopause

Men's Health

Midwifery

Minimally Invasive Surgery

Mobile Intensive Care Unit

Nephrology

Neurology

Neurology - Pediatric

Neurosurgery

NICU and Special Care Nursery

Obstetrics and Gynecology

Occupational Health

Oncology Nurse Navigation

Ophthalmology - Pediatric

Orthopedics

Orthopedics - Pediatric

Otolaryngology - Pediatric

Ovarian Cancer

Pain Management

Palliative Medicine

Partial Knee Replacement

Pathology

Pediatric Services

Personal Health Navigator

Physical Therapy and Rehabilitation

Podiatry/Foot and Ankle Surgery

Post-Acute Care

Pregnancy and Infant Loss Support

Prenatal Testing/Genetic Counseling

Primary Care

Prostate Cancer

Psychiatry

Pulmonary Medicine

Pulmonology - Pediatric

Quad-Sparing Knee Replacement

Radiation Oncology

Radiology Imaging

Robotic Surgery

Seniors Health

Sexual Health

Sexual Wellness and Pelvic Health

Shoulder Arthroscopy

Skin Cancer

Skin Care and Massage

Sleep Lab - Pediatric

Sleep Medicine

Spa Services

Spine Surgery

Sports Medicine

Sports Medicine Kids

Stroke

Surgery

Surgery and Anesthesia - Pediatric

Teleneurology

Testicular Cancer

Thoracic Surgery

Thyroid Cancer

Type 1 Diabetes

Type 2 Diabetes

Urgent Care

Urology

Urology - Pediatric

Uterine Cancer

Vascular Surgery

Vir tu Spa

Virtua Baby

Virtua for Women

Virtua Medical Group

Virtua Paramedic Education

Weight Loss and Wellness Center

Women's Cardiology

Women's Health

Wound Healing
Patient Tools
Most Viewed Patient Tools
View All Patient Tools
I Want to...

Go

Find A Doctor
- Primary & Specialty Care
- Pediatrics
Locations
Most Viewed Locations
View All Locations
Locations Search
Services
Most Viewed Services
View All Services
Services Search

Services A-Z
A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

R

S

T

U

V

W

X

Y

Z

Adolescent Gynecology

Allergy and Immunology - Pediatric

Angioplasty

Arthritis

Arthroscopic Surgery

Balance Testing and Care

Bariatric Weight-Loss Surgery

Behavioral and Mental Health

Behavioral Health - Pediatric (CASTLE)

Bio-identical HRT

Bladder Cancer

Brain and Spine

Brain Surgery

Breast Cancer

Breast Health and Mammograms

Breast Reconstruction

Breastfeeding

Cancer Genetic Counseling and Testing

Cancer Support Services

Cancer Surgery

Cancer Treatment

Cardiac Catheterization

Cardiac Rehabilitation

Cardiology - Pediatric

Cardiovascular Health

CASTLE

Cervical Cancer

Chemotherapy

Chest Pain Care

CHOP at Virtua

Clinical Trials

Colonoscopy

Colorectal Cancer

Colorectal Surgery

Concussion/ImPACT Testing

Cosmetic Plastic Surgery

Critical Care - Pediatric (PICU)

Dentistry

Depression and Pregnancy

Dermatology

Diabetes Care

Diagnostic Imaging - Pediatric

Diet and Wellness Coaching

Ear, Nose and Throat (ENT)

Early Intervention Program

Emergency Medical Services

Emergency Medicine

Emergency Services - Pediatric

EMS Continuing Education

Endocrinology - Pediatric

Exuberan

Eye Care

Family Medicine

Female Pelvic Health

Fitness

Gastroenterology

Gastroenterology - Pediatric

Geriatric Care Management

Gestational Diabetes

Gynecologic Oncology

Hand Surgery and Rehabilitation

Healthy Eating

Heart Disease And Pregnancy

High-Risk Pregnancy Care

Hip Preservation

Hip Replacement

Home Health Care

Hospice Care

Hyperbaric Oxygen Therapy

Immunotherapy

Infertility

Internal Medicine

Joint Replacement Institute

Kidney Cancer

Knee Replacement

Lab Services

LifeCare

Long-Term Care and Rehabilitation

Lung Cancer

Lung Wellness Program

Lymphoma

Maternity

Medical Nutrition Therapy

Medical Oncology

Medical Weight Loss

Menopause

Men's Health

Midwifery

Minimally Invasive Surgery

Mobile Intensive Care Unit

Nephrology

Neurology

Neurology - Pediatric

Neurosurgery

NICU and Special Care Nursery

Obstetrics and Gynecology

Occupational Health

Oncology Nurse Navigation

Ophthalmology - Pediatric

Orthopedics

Orthopedics - Pediatric

Otolaryngology - Pediatric

Ovarian Cancer

Pain Management

Palliative Medicine

Partial Knee Replacement

Pathology

Pediatric Services

Personal Health Navigator

Physical Therapy and Rehabilitation

Podiatry/Foot and Ankle Surgery

Post-Acute Care

Pregnancy and Infant Loss Support

Prenatal Testing/Genetic Counseling

Primary Care

Prostate Cancer

Psychiatry

Pulmonary Medicine

Pulmonology - Pediatric

Quad-Sparing Knee Replacement

Radiation Oncology

Radiology Imaging

Robotic Surgery

Seniors Health

Sexual Health

Sexual Wellness and Pelvic Health

Shoulder Arthroscopy

Skin Cancer

Skin Care and Massage

Sleep Lab - Pediatric

Sleep Medicine

Spa Services

Spine Surgery

Sports Medicine

Sports Medicine Kids

Stroke

Surgery

Surgery and Anesthesia - Pediatric

Teleneurology

Testicular Cancer

Thoracic Surgery

Thyroid Cancer

Type 1 Diabetes

Type 2 Diabetes

Urgent Care

Urology

Urology - Pediatric

Uterine Cancer

Vascular Surgery

Vir tu Spa

Virtua Baby

Virtua for Women

Virtua Medical Group

Virtua Paramedic Education

Weight Loss and Wellness Center

Women's Cardiology

Women's Health

Wound Healing
Patient Tools
Most Viewed Patient Tools
View All Patient Tools

Live Chat
My Virtua
Careers
Classes & Events
Giving
About Us

Close

Student/Instructor Documentation Checklist

Read our Website Privacy Policy
denotes required field

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.

Accept

Decline

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

Student Profile

Undergraduate

Pre-Licensure Student

Graduate Non-Nursing

Graduate

Academic Organization

Other

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

Virtua Employee?

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

Program of Study

Other

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

Phone Number

Email Address

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

1-888-847-8823
Request a Callback
Live Chat

PATIENT TOOLS

Pay Bill
Pre-Registration Forms
Health Insurance
My Virtua
Online Nursery
Patient Bill of Rights
Notice of Non-Discrimination

ABOUT VIRTUA

About Us
Careers
Classes & Events
News Releases
Community
Leadership
Quality
Virtua Foundation
Virtua Medical Group

EMPLOYEES & PHYSICIANS

For Employees
For Physicians
Physician Exchange Portal
Continuing Medical Education
Graduate Medical Education

Copyright © 2000-2019 Virtua | Privacy Policy | Terms of Use | Sitemap