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Medical Professionals

New Student Orientation Form

Basic Information

 Student First Name  *Student Middle/Maiden Name/Nickname Student Last Name  *Student Email Address  *Student Date of Birth  *School Name  *Degree/Program Teaching  *Rotation Start Date  *Rotation End Date  *Total Clinical Hours  *  

School Representative Information

 School Representative First Name  *School Representative Last Name  *School Representative Phone Number  *School Representative Email Address  *  

Piedmont Entity Information

 Select one entity  *
Select one department If your department is not listed above, enter it here Department Contact/Office Manager Select one department If a department is not listed, enter it below: Department Contact/Office Manager Select one department If a department is not listed, enter it below: Department Contact/Office Manager Select a department If a department is not listed, enter it below: Department Contact/Office Manager Select one department If a department is not listed, enter it below: Department Contact/Office Manager Select a practice/location If a practice/location is not listed, enter it below: Department Contact/Office Manager For physician practice rotations, enter any included hospitals & depts.   

Piedmont Contact Information

 Piedmont Coordinator  *Piedmont Dept Contact First Name  *Piedmont Dept Contact Last Name  *Piedmont Dept Contact Email Address  *Piedmont Preceptor First Name  *Piedmont Preceptor Last Name  *Piedmont Preceptor Email Address  *Student will be supervised by  *AHA BLS/CPR Certification Expiration Date Note: All students involved in patient care are required to list a current BLS expiration date. Personal Health Insurance  *Note: If the student does not have personal health insurance, any health care that is required will be at the sole expense and responsibility of the student. Professional Liability  *Note: Copy on file with Legal Department Online orientation materials reviewed  *  

Tuberculosis

Piedmont Healthcare will accept any of the following documentation and must be free of the following symptoms: productive cough lasting more than three weeks, unexplained fatigue, night sweats, unexplained weight loss, unexplained fever, chills or coughing/spitting up blood.

  • Negative two-step TB skin test (Step 1 within the last 12 months and Step 2 within the last 90 days) for all initial student rotations within Piedmont Healthcare.

  • Negative T.Spot or Quantiferon Gold blood test within the last 12 months.

  • For history of positive TB test, latent TB infection or TB disease, must have negative chest x-ray. If student has had TB disease, medical evaluation that student has been treated for TB disease is required.

  • After initial TB testing is completed, student should receive follow-up TB testing annually consisting of a one-step TB skin test or a T.SPOT or a Quantiferon Gold Test.

 
 Select one 
Date Result Second Date Second Result Date Result   If Positive, please answer the next 2 questions: 1. Have you had a chest x-ray? If yes, when? Results   2. Have you been treated with Anti-Tubercular Drugs? If yes, when? Length of treatment   

M.M.R. (Measles, Mumps and Rubella)

Complete one option. Proof of documentation must be available upon request. 
 MMR Dose 
First Dose Second Dose First Dose of Measles Second Dose of Measles First Dose of Mumps Second Dose of Mumps First Dose of Rubella Measles Mumps Rubella   

Varicella (Chicken Pox)

Complete one of the following options. Proof of documentation must be available upon request. 
 Select one  *
Date of Positive Varicella titer Date of first Varivax immunization Date of second Varivax immunization   

Hepatitis B Vaccine

Hepatitis B vaccines are offered and encouraged for all direct patient care providers. In lieu of the Hepatitis B vaccine, participant shall provide a signed declination. Proof of documentation must be available upon request. 
 Series Dates Date of first vaccination Date of second vaccination Date of third vaccination Hepatitis Antibody titer   
  
  

Tetanus/Tdap

Tetanus should be given within the last 10 years. Tdap is recommended on mother/baby units. Defer if last Tetanus was administered within 2 years. Proof of documentation must be available upon request. 
 Last Tetanus immunization Date Tdap given date   
 
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