Clinical Experience Form Select Role* Select oneStudent/Individual seeking a clinical experienceSchool seeking a clinical affiliationInstructor uploading student roster for clearance Student Application Name* First Middle Last Phone* Email (School) Address* License No./NPI: Student?* Select oneYesNo School:* Student ID* Beginning Date:* Date Format: MM slash DD slash YYYY Ending Date:* Date Format: MM slash DD slash YYYY *for multiple rotation requests please complete an additional application Specialty Area:* (FP/IM/Pediatrics/etc.) Number of Hours:* Preceptor Requirements:* (i.e. APRN only, or APRN/MD/DO, PhD, etc.) Preceptor Name: (If identified) Stormont Vail Health employee?* Select oneYesNo Please detail how Stormont Vail/Cotton O’Neil were chosen for this request:* School Seeking Clinical Affiliation Name of School Contact Seeking Affiliation* First Middle Last Phone Number* Email Address* School:* Program:* Location:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Number of Student Rotations:* Anticipated Beginning Date of Rotations:* Date Format: MM slash DD slash YYYY Please describe how Stormont Vail Health was selected for this request:* Instructor/School Contact Uploading Roster Name of Instructor/School Contact Uploading Student Roster:* First Middle Last Phone Number:* Email Address:* School:* Program:* Semester:* This section is for instructors/school contacts of programs with current affiliation agreements with Stormont Vail Health. By uploading the completed student roster, I am attesting on behalf of my School that all of the following required documentation for a clinical experience at Stormont Vail has been collected, validated, and will be maintained for a minimum of seven years: Hepatitis B – documentation of 3-dose vaccination series MMR – documentation of 2-dose vaccination series or laboratory evidence of disease or immunity Varicella – documentation of 2-dose vaccination series or proof of a positive immunity serology result Tdap – documentation supporting one Tdap Criminal background check and urine drug screening records Documentation of personal health insurance Verification of good standing in the program Confidentiality Agreement (signed by student and School) Documentation of liability insurance coverage Middle initial (for computer access request) Student ID # (for computer access request) Kansas license number TB Questionnaire Negative TB test results read within the last 12 months (must include facility/provider, the plant and read date, and the results in mm) Proof of seasonal influenza vaccination (October-March) Download link Download link Download link Upload completed student roster* Comments This field is for validation purposes and should be left unchanged.