Student Orientation Form - Faculty

Basic Information


 
Faculty First Name  *Faculty Middle/Maiden Name/Nickname Faculty Last Name  *Faculty Email Address  *Faculty Date of Birth  *School Name  *Degree/Program Teaching  *  

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


 
AHA BLS/CPR Certification Expiration Date  *Note: All faculty involved in patient care are required to list a current BLS expiration date. Personal Health Insurance  *Note: If the faculty member does not have personal health insurance, any health care that is required will be at the sole expense and responsibility of the faculty member. Professional Liability  *Note: Copy on file with Legal Department Nursing License #  *  

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 30 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 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