Clinical Experience Form - Stormont Vail Health

Select Role*
Student Application
Name*

First

Middle

Last
Phone*
Email (School) Address*
License No./NPI:
Student?*
Student Type*

(EMT, CNA, Scribing, Shadowing, etc.)
School:*
Student ID*
Beginning Date:*

MM slash DD slash YYYY
Ending Date:*

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?*
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

State

ZIP Code
Number of Student Rotations:*
Anticipated Beginning Date of Rotations:*

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 or 3-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)
- TB Questionnaire
- Proof of past negative TB test results (must include facility/provider, the plant and read date, and the results in mm)
- Proof of seasonal influenza vaccination (October-March)
Upload completed student roster*
Max. file size: 98 MB.
Phone

This field is for validation purposes and should be left unchanged.

Student Application

School Seeking Clinical Affiliation

Instructor/School Contact Uploading Roster