Clinical Site Information


Students

  • Student Information

    • No clinical paperwork to complete
  • Student Information

    Please use Internet Explorer

    1. Please print and complete the Student Cover Page and Checklist.  All information must be filled out including medical information.
    2. Review and complete all documents (zip file), follow the Student Cover Page and Checklist.  Signatures cannot be electronic.  Documents not fully completed will not be accepted by the VA. 
    3. You must have your Driver’s License on hand at orientation.

    Submit all documents including copies of your medical documents to Jeannette Clarke in room 3004.

    Medical and Clinical document Checklist to be submitted to room 3004:

    • Student Cover Page and Checklist (2 completed pages)
    • VA Application for Health Professions Trainees (4 pages)
    • Declaration for Federal Employment (2 pages)
    • Orientation Tests for Nursing Students  with your answers circled (5 pages)
      • Includes:  Atlanta VAMC Nursing Education, Safe Patient Handling and Movement, Cardiopulmonary Resuscitation, Restraints and Seclusion, Code 44.
    • Three Certificates of completion:  (3 pages – use the TMS Help Resources – Students User for assistance as listed on your student cover page)
      • 1) VHA Mandatory Training For Trainees
      • 2) Privacy & HIPPAA Training
      • 3) Survey Completion Certificate
    • Varicella Guidelines and Waiver
    • HepB Vaccine Waiver Statement
    • Proof of Tetanus
    • Proof of MMR, Varicella and HepB titer reports or proof of immunizations
    • Negative PPD, Quantiferon or  Chest X-ray within 12 months which may not expire during your clinical rotation
    • Front and back copy of your CPR card
    • You can submit the first page of your physical if fully completed with current immunizations.
  • Student Information

    • Student Information - No paperwork.
  • Student Information

    • Print a copy of your full Background Check from Advantage Students and E-mail to Susie Gloth at sgloth@cartersville.k12.ga.us two weeks prior to the first day of clinical.
    • In the subject line type: KSU Clinical Background Check Report.
  • Student Information

    Student’s please WAIT for further instruction before you fill out any forms!

    1. Go to http://tcps-us.com

    2. Read and follow the instructions to access your credentialing documents

    4417 Preceptorship ONLY

    In addition to completing steps above, you must schedule a time with Robbie Tatum (robbie.tatum@hcahealthcare.com) 15 days before your first day of clinical to watch the Code of Conduct Video (1hr video). In the e-mail subject line: KSU Code of Conduct Schedule & Badge.

    Medical Documents
    (must be submitted with your clinical paperwork)

    1. Front and back copy of your current cpr card
    2. Immunizations 
      • PPD (Must provide one of the following)
        • Negative PPD: Negative PPD within 90 days
          If your PPD is not within 90 days Cartersville Medical Center requires you to have another test administered. Contact your Personal Health Care Provider or you can have the test done at the KSU Clinic, the cost is $17.00 (may be less depending on insurance) / call 470-578-6644 to schedule an appointment (The updated PPD must be submitted with your clinical paperwork).
        • Positive PPD: Chest X-ray or radiology report within the last 12 months and documentation of taken prophylactic medication
        • Quantiferon: Must be negative result
      • Proof of tetanus immunization
      • Proof of Varicella or titer value report
      • Proof of two MMR immunization or titer value report
      • Proof of three Hepatitis B immunization or titer value report
      • Current Flu documentation

    Document Checklist

    • iCARE Standards
    • Confidentiality and Security Agreement 
    • Orientation Education Test 
    • Attestation Form for Student Personnel 
    • All Immunizations (listed above)
    • Front and back copy of your current CPR Card
  • Student Information

    1. Complete Internship Volunteer Paperwork

    2. Please provide the additional documents:

      Copy of background check
      Copy of state ID
      Copy of school ID
    3. After completion of above documents please submit to Room 3004 or e-mail to nu_medrecords@kennesaw.edu

  • Student Information

    Fill out the following forms and turn in to Jeannette Clarke in HS 3004:

  • Student Information

    1. If you have been assigned to CHOA you will receive an e-mail from Symplr providing instructions. Credentialing for CHOA will cost $49
    2. If you do not receive Symplr’s e-mail 1 week after notification of placement please contact Jeannette Clarke at jclar276@kennesaw.edu
    3. Please read Symplr’s instructions carefully, detailed information is listed for required uploads and documentation
    4. Manager should be listed in Symplr as Jeannette Clarke jclar276@kennesaw.edu, 470-578-2890
    5. If you receive a denial for any reason on any portion,  please notify Jeannette Clarke at jclar276@kennesaw.edu 
    6. Liability Insurance letters will be e-mailed to each student by WSON to satisfy this requirement
    7. CHOA does their own background check through Symplr, you can print your drug screen from Advantage Students and upload the results to satisfy the drug test requirement
    8. CHOA encourages you to download the Symplr Mobile App (after connecting to their site you can upload required documents and it will provide you with real time compliance status)
    9. Symplr will show green light status when you have completed each portion of credentialing
    10. Parking Information
      • Scottish Rite: Clinical Instructors/Faculty/Clinical Groups/Pracitcum Students can park in the main deck. The badge will grant access to parking deck through Employee Entrance/Exit.

      • Egleston: Clinical Instructors/Faculty/Clinical Groups/Pracitcum Students cannot park in the main decks (T1 & T2) during peaks hours. Designated off-site parking for students has been identified at the CHOA Administrative Park located on Tullie Circle. Shuttles operate from this location on Monday through Friday, 5:00 AM to 9:00 PM.

        In order to park at the Administrative Center (spaces surrounding the building formerly known as Piccadilly), staff must contact the Egleston Parking Department at 404-785-6696. Advanced notice is required. Staff must complete a car registration form and obtain a decal prior to parking at Piccadilly.

        *Exception: During the weekend or those working an overnight shift, instructors/students may park in either of the main hospital decks. In order to do this, one must pull a ticket and have it validated at the front desk. 

      • Hughes Spalding: Clinical Instructors/Faculty/Clinical Groups/Pracitcum Students cannot park directly at the Hughes Spalding deck. Students and faculty are to park at the Butler deck (148 Jesse Hill Jr. Drive, Atlanta 30303; just past Grady Hospital, next to McDonald's)—enter on visitor's side, pull a ticket, and bring ticket with them for validation.

    In the event you have an issue with one of the requirements please contact Jeannette Clarke at jclar276@kennesaw.edu for resolution

  • Student Information

    Cobb County:
    Ready to Work
    Hartmann Center
    Ready to Work Program
    Mothers Making A Change
    Cobb Crisis Stabilization
    Cobb Recover Center
    Dual Diagnosis

    1. Read the Handbook
    2. Intern Acknowledgement
      • Your signature and Date
    3. Intern Application
      • 1st Page
        • Name:  Print your name
        • Date: Todays date and day time phone number
        • Dates for placement/internship & Days and time available for placement/internship: begin and end date will be entered for you.
        • School, College, Institution: Kennesaw State University
        • Degree of Certification Desired: BSN   Major: Nursing
        • Program Course for which placement/internship is required: 3314
        • Projected Graduation Date: Semester and Year of graduation
        • Answer questions 1-3
        • Don’t complete #4 or #5
      • 2nd Page
        • Don’t complete this page, but submit with your paperwork
    4. Intern Policy Signature Sheet  
      • Complete entire form
      • Initial number 1-10
    5. Confidentiality & Technology for Interns – submit only page 2
      • Employee/Volunteer/Intern/Signature: your signature and todays date
      • Print Full Name: Print your name
      • Witness Signature: Have your family of friend to be your witness and date
    6. Release for information – This forms must be fully completed or you will not be able to start clinical
      • Print clearly filing in ALL information
      • Must Include
        • SSN: Your SSN
        • Phone Number: Daytime Phone Number
        • Email: KSU E-mail address
        • Signature of Applicant/Employee: Your signature and date
    7. Drug Free Work Place
      • Print and sign your name
    8. Read the HIPAA Presentation and Complete HIPAA for Intern Test
      • Complete and submit
    9. Read and complete the Infection Control Orientation Packet and Quiz and submit
      • Complete and submit
    10. Check your Infection Control Orientation Quiz & Acknowledgement
    11. Infection Control Signature
      • Employee/Volunteer/Intern/Contractor Signature:  Your signature and date
    12. Person-Center Ed Services
    13. Complete the Affidavit
    14. Your clinical instructor will contact you to schedule an appointment for drug testing and to complete the necessary paper work for Human Resources

    Medical Documents
    (must be submitted with your clinical paperwork)

    1. Current PPD within 1year or chest x-ray report
      • You must take to your appointment:
        • Social Security Card (passport or birth certificate if student does not have SS card)
        • Driver's License
      • Go to www.cobbcsb.com and read the information on these policies:  4081 Equal employment & Unlawful Conduct, 4089 Standards of Conduct Policy, 4079 Cultural Competency And Diversity Plan, 4053 Sexual Harassment Policy, 4088 Workplace Violent Prevention Policy, 3004 No Smoking Policy, Drug-Free Workplace.  After you have read the following policies including the attached Person Centered Services Page and completed the intern application, sign the Policy signature sheet.

    Document Checklist

    •  Intern Acknowledgment
    •  Intern Application  (2 pages)
    •  Intern Policy Signature Sheet
    •  Confidentiality and Technology for Interns
    •  Release for information
    •  Drug Free Work Place
    •  HIPAA Test
    •  Infection Control Orientation Quiz & Acknowledgement
    •  Current PPD or Chest X-ray
    •  Affidavit
  • Student Information

    • All forms to be completed onsite the first day of clinical (please take driver's license)
    • Bring a copy of your Advantage Students background check and drug screen with you to Orientation
    • Orientation must be completed prior to clinical rotation start date. Your instructor will contact you with further instructions.
  • Student Information

    • Click on assigned camp website and complete Volunteer Application
    • If Letters of Recommendations are required, submit recommendations sealed in separate envelopes with your Camp Application
    • Submit completed applications and letters of recommendations (if applicable) at HS 3004 NO FAXES
    • Camp Braveheart

      Children's Healthcare of Atlanta
      1405 Clifton Road, NE
      Atlanta, GA 30322-1062
      Phone: 404-785-6735
      Toll Free: 800-542-2233
      Website (click here)

      For kids with heart defects and heart transplant recipients.

      • Camp Breathe Easy

        American Lung Association in Georgia
        2452 Spring Road
        Smyrna, GA 30080
        Phone: 404-231-9887 x223
        Website (click here)

        For kids with asthma.

        • Camp High Five

          H.E.R.O. For Children
          4497 South Old Peachtree Road
          Norcross, GA 30071
          Phone: 404-616-9809
          Website (click here)

          For kids who are affected by HIV.

          • Camp Independence

            National Kidney Foundation serving Georgia
            2951 Flowers Road South, Suite 211
            Atlanta, GA 30341
            Phone: 770-452-1539, ext. 20
            Toll Free: 800-633-2339
            Website (click here)

            For kids with kidney disorders and transplants.

            • Camp Krazy Legs

              Kids with spina bifida
              Website (click here)
              • Camp Kudzu

                577 Concord Rd. SE – Suite B
                Smyrna, GA 30082-2609
                Phone: 404-250-1811
                Website (click here)

                For kids living with type I diabetes.
                Submit the application online
                • Camp New Hope

                  Sickle Cell Foundation of Georgia
                  2391 Benjamin E. Mays Drive
                  Atlanta, GA 30311
                  Phone: 404-755-1641
                  Website (click here)

                  For kids with sickle cell disease.
                  • Camp No Limb-itations

                    Kids with limb defects
                    Website (click here)
                    • Camp Strong4Life

                      Focus on health and weight
                      Website (click here)
                    • Student Information

                      • No special requirements.
                    • Student Information

                      • Print a copy of your full background Check and drug screening from Advantage Students and fax to Pam Houser at 770-220-2979 10 days before your fist day of clinical.
                      • In the subject line type: KSU Clinical Background Check and Drug Screening Report.
                      • Clinical Paperwork will be completed at the clinical site.
                    • Student Information

                      DCSB Vendor Packet

                      Document Checklist

                      • Personal Data Form (1 page)
                      • Drug Free Workplace Acknowledgement Form (1 page)
                      • DCSB Terms and Conditions of Employment (1 page)
                      • Investigation Acknowledgement Attestation (1 page)
                      • Employment of Relatives (1 page)
                      • Immunitrax Health Record Summary page (1 page)
                    • Student Information

                      Students please view and complete documents for clinical rotation

                      • After completion of documents please submit
                        • EMAR assessment
                        • EMAR med-surg assessment
                        • OMM assessment
                      1. Review Training Powerpoint
                      2. Complete Sunrise Clinical Assessment
                        • Name: Print your first and last name
                        • Date: Todays Date
                        • Nursing School: Kennesaw State University
                        • Complete Test
                      3. Complete Clinical Orientation Check off Sheet
                        • Initial each heading
                        • Student Name: Print your name
                        • Student Signature: Your Signature
                        • College/School: Kennesaw State University
                        • Semester/Year: Spring, Summer or Fall / current year
                      4. Review and complete User Access and Confidentiality Agreement
                        • Enter Date (page 1)
                        • Enter your name (page 1)
                        • Under “User” 2nd column  (page 4)
                        • By: Sign your name
                        • Name: Print your name
                        • Title: Nursing Student
                        • Date: Todays date
                        • Non-Employee System Access Request Form (page 5)
                        • Non-Employee Name: Your Name
                        • Company Name: Kennesaw State University
                        • Address: 1000 Chastain Road   Kennesaw, GA 30144
                        • Phone Number: Your day time telephone number
                        • Fax Number: N/A
                        • E-mail Address: Your KSU E-mail address 
                      5. Review and complete EXHIBIT B
                        • Institution: Kennesaw State University
                        • Date: Enter todays date
                        • Student Signature: Your signature
                        • Please Print Name: Print your name
                        • Witness Signature: Have a witness to sign their name
                        • Please Print Name: Have the witness above to print their name
                      6. Log into your Advantage Student Account and select DeKalb Medical to view your results

                      Document Checklist

                      •  Sunrise Clinical Assessment (5 pages)
                      •  Clinical Orientation Check off Sheet (1 page)
                      •  User Access and Confidentiality Agreement (5 pages)
                      •  Exhibit B (1 page)
                    • Student Information

                      • Please read and complete the site's paperwork
                      • Bring completed paperwork with you to the site
                    • Student Information

                      No requirements at this time

                    • Student Information

                      Complete the Student Packet

                      Return all forms to nu_medrecords@kennesaw.edu or slip copies under the door of Room 3004 (do not fax forms to the number listed on the packet)

                      Complete the Privacy and Security Training in the attached packet

                      Ensure all witness signatures have been completed
                      (Department/Section is Nursing)

                      Please ensure Emory Johns Creek Hospital is selected in Advantage Students to access criminal background check and drug screen 

                      Document Checklist

                      • Copy of Status Page from Immunitrax
                      • Copy of Influenza vaccination
                      • Copy of Current Insurance Card
                      • Acknowledgement of Privacy and Security Awareness Training
                      • Confidentiality Statement
                      • Authorization to Release Student Records (signature must be witnessed)
                      • Student Agreement Concerning Education Training Program (hand in page 2, signature must be witnessed)
                      • Agreement Concerning Faculty Supervision of Educational Training Program  (hand in page 2, signature must be witnessed)
                      • EJCH Request Access Form (do not fax document to Emory as stated on bottom of document, complete in full, Unit is Nursing – Agency is KSU, 1000 Chastain Rd., Kennesaw, GA 30144 – leave Sponsor name and logon ID blank)
                    • Student Information

                      See link below to obtain clinical documents
                      Emory Healthcare Nursing Students & Faculty

                      Emory University Hospital Midtown Only:

                      • Badge office hours are M-F 7-3:30 (closed for lunch from 12:30-1:00), located on the first floor of the Orr Building.
                      • Students are required to find parking in other pay lots.

                      Medical Documents 
                      (must be submitted with your clinical paperwork)

                      • Flu Vaccine for current flu season

                        Flu Vaccine is required for all students. For fall clinical rotations flu vaccine documentation is required by October 31st. For spring and summer clinical rotations flu vaccine documentation is required before clinical rotations start.

                      • A copy of your current medical insurance card (front and back)

                      Document Checklist

                      • Current Medical Insurance Card (front and back)
                      • HIPAA Form (1 page)
                      • Confidentiality Statement (1 Page)
                      • Student Agreement (submit 2nd page)
                      • Authorization To Release Student Records (1Page)
                      • Parking Request (Midtown Only)
                      • Current Flu Vaccine
                      • Computer Logon Request Form
                      • Student Computer Access Request Form (John's Creek Only)
                    • Student Information

                      Floyd Medical Center uses a credentialing tool called Rotation Manager. Click on the links below to, first, watch the student video and, second, learn about how to sign up and use Rotation Manager.

                      student video rotation manager

                       

                    • Student Information

                      • No special requirements.
                    • Student Information

                      • No special requirements.
                    • Student Information

                    • Student Information

                      1. Go to www.gordonhospital.com
                      2. Search for "Human Resource Packet" in the search bar on the top right
                      3. Go to "Student Packet"
                      4. Complete all information as requested to include reading all informational resources and signing/completing all documentation
                      5. Scan and e-mail documents to nu_medrecords@kennesaw.edu (or bring to room 3004 and slip them under the door)
                      6. Contact Clinical Informatics Educator – 706-879-4745 ext. 2625 to complete computer training (computer training is the third week of every month)
                      7. Please print out background and drug screen (entire document) and e-mail it to Sharon.Hailston@AHSS.ORG before you go to computer training.

                      Medical Documents
                      (must be submitted with your clinical paperwork)

                      Immunizations

                      1. PPD (Submit one of the following):
                        • Negative PPD: Negative ppd within 90 days
                          • If your PPD is older than 90 days you must have another PPD done and submitted with your clinical paperwork
                          • Contact your health care provider or KSU clinic @ 470-578-6644 the cost is $17.00
                        • Positive PPD: Chest X-ray or radiology report within the last 12 months
                        • Quantiferon: Must be negative result
                      2. Proof of tetanus immunization
                      3. Proof of Varicella or titer value report
                      4. Proof of two MMR immunization or titer value report
                      5. Proof of three Hepatitis B immunization or titer value report
                      6. Flu Vaccine:
                        • Fall semester: flu documentation must be submitted by 2nd Friday in October
                        • Spring semester: flu documentation must be submitted with clinical paperwork.

                      You can submit page one of your physical, attach additional immunization documents to ensure all above medical requirements are met.

                      Document Checklist

                    • Student Information

                      *when signing up with ACEMAPP only use your KSU e-mail.

                      1. You will receive an invitation to purchase ACEMAPP, please watch your KSU e-mail and purchase it as soon as possible
                      2. Complete all required documentation and log in frequently to assess your progress.  If you do not receive an invitation please e-mail nu_medrecords@kennesaw.edu

                        ACEMAPP Student Checklist

                      3. Sign up for orientation on ACEMAPP

                        Orientation Calendar

                      4. Log into your Advantage account and select Grady Health System to view your results
                      5. All students will be required to pay $1.00 badge fee to Grady Hospital before receiving their badge. Community and Practicum Students, badges must be picked up no sooner than 3 days prior to the beginning date of your clinical rotation, you will be unable to begin your rotation without your badge.
                      6. Parking is $6.00 a day

                      Health Clearance Requirements for Grady

                      • Attach a copy of your Immunitrax Record to your clinical documentation showing all Health Requirements have been met or you are on schedule with all in series vaccinations

                        Grady Clinical Health Requirements

                      Maternal Health 3318 Students ONLY:

                      • Students will be required to obtain an additional fingerprinting package from Advantage Students at a cost of $46.25. Please follow the directions and your instructor will inform you when you have been cleared. Do not delay, this takes additional time and you will not be able to start your rotation until it has been completed through Advantage. 
                      • Choose the selection “Grady Hospital - Intern Fingerprinting” as your school / program, after downloading the advantage student document with the directions.
                    • Student Information

                      • Go to the Gwinnett Medical Center Website.  
                      • Follow all directions for the student Orientation Requirements.  Return all documents that state “print” to Jeannette Clarke (not your instructor) room 3004.
                      • Add Gwinnett Medical Center to your Advantage Students account.

                      Document Checklist

                      •  Authorization for Release of Records and Information
                      •  Student Applied Learning Experience Agreement
                      •  Student ID Access control
                      •  Environment Of Care Acknowledgment
                      •  Information Privacy/Security Training Acknowledgement
                      •  Workforce Confidentiality Agreement
                      •  Code of Conduct Acknowledgment
                      •  Corporate Compliance Test
                      •  Infection Prevention and Control Acknowledgment
                      •  Influenza Prevention Test
                      •  Isolation Precautions Acknowledgment
                      •  TB Prevention Acknowledgement
                      •  MRI Form
                      •  MRI Safety Acknowledgement
                      •  Effective ALT communication Acknowledgment
                      •  Service Excellence Standards
                      •  Service Excellence Acknowledgement
                      •  Student Facility Acknowledgment
                      •  Student Authorization for Record Release
                      •  Student Educational Program Training Agreement
                      •  Glucose Test
                      •  Glucose Comp
                      •  NPSG Acknowledgement
                      •  OR Protocol Acknowledge
                      •  Photo of yourself headshot plain background
                    • Student Information

                      • Visit: https://students.floyd.org
                      • Student will need to click on sign up in top right corner of website and then use this code to proceed.
                        Access Code: admin_signup_code
                    • Student Information

                      • No special requirements.
                    • Student Information

                      • Fax a completed PPD with values and this form to Melissa Brown at 770-218-1975

                      Document Checklist

                      • PPD
                      • Background Driving Record Check Form
                    • Student Information

                      • No special requirements.
                      • Homstead Hospice will contact you with orientation dates.
                    • Student Information

                      • Kaiser Permanente will contact you 2-3 weeks before your clinical rotation begins.
                    • Student Information

                      Since the KSU Health Clinic is now part of the WellStar Health System, see WellStar Health System (Kennestone, Cobb, Windy Hill, Paulding, Douglas and First Steps) below and follow the instructions.

                    • Student Information

                      Complete General Application for Employment.

                      • You do not need to complete the tax and background forms that are listed in the packet
                      • Complete, sign, and return to Room 3004
                    • Student Information

                      Thirty days before your clinical start date, students must arrange for a free drug screen and criminal background check.  Please contact Ms. Almenta Baker at 770-528-4252 or Ms. Tammy Bundrage at 770-528-4202 to schedule an appointment to complete your paperwork and have your fingerprints taken.

                      You must produce your social security card and driver’s license to the facility at the background check.

                      Be prepared, you will be asked specific questions regarding your background (previous addresses, traffic violation dates etc.). You will not be allowed to bring your cell phone in the building so secure it before you enter. The door to access the correct office once you have arrived is labeled “visitation” not “intake”

                      Location:
                      1575 County Services Parkway
                      Marietta, GA 30008

                    • Student Information

                      • Please contact MedSide Healthcare Corporation -  Home Health Administrator Beatrice Coulombe to register for your Orientation.  Orientation must be completed prior to the start date of your clinical rotation.  Orientation is conducted every Monday from 9:30am to 3:30pm. 
                      • Complete the attached paperwork fully and bring everything to your scheduled Orientation.

                      Document Checklist

                      • Authorization to Request Records (2 separate forms, 1 page each)
                      • Consent to Photograph (1 page)
                      • Post – Offer Health Screen (3 Pages)
                      • Chamblee Police Department Criminal History Consent Form (1 page)
                      • Confidentiality Agreement (4 pages)
                    • Student Information

                      North Fulton Regional Packet
                      1. Please read and complete the North Fulton Regional packet and return to jclar276@kennesaw.edu

                      2. Please make sure Immunitrax is current and up to date  (PPD and CPR card cannot expire during the semester)

                      3. Log into your Advantage account and Share your background check with North Fulton Regional Hospital and WellStar

                      4. Contact Carol Jones at 770-751-2825 to schedule orientation

                      Document Checklist

                      • North Fulton Hospital Student Clincal Rotation Guidelines
                      • WellStar Nursing Student Information
                      • Medical Expense Waiver
                      • Confidentiality & Technology Acceptance Agreement
                    • Student Information

                      1. Please refer to Northside's website.
                      2. Click on the Orientation Link (top of the page in navy blue – far right)
                      3. The page should say Northside Hospital – Secure Log-in and have a password box
                      4. Enter "classroom" (all lowercase letters) in the box
                      5. Click on Students Credentialing (box on left, middle of page)
                      6. Click on which type of student you are – Northside Employee or Non-Northside
                      7. Click on Student Credentialing Checklist
                      8. Complete and submit: forms are highlighted in blue and underlined click to access

                      Please read the online orientation. Any questions should be directed to your instructor.

                      4417 senior practicum students do not report to your unit before picking up your badge, instructions to do so will be given to you by your clinical instructor.  

                      Medical Documents
                      (must be submitted with your clinical paperwork)

                      • Front and back copy of your current cpr card
                      • Immunizations
                          • TB (submit proof of two consecutive negative TB results):
                              • Negative PPD: Negative PPD within 12 months and a PPD within 60 days prior to clinical start date OR 2 annual negative PPD’s
                              • Positive PPD:  Negative Quantiferon Gold within 60 days prior to clinical start date (May also need a CXR if in high risk area like OB)
                              • Positive Quantiferon:  Negative Annual Chest X-ray with report read and signed by MD
                              • Positive Chest X-Ray:  Need evidence of INH or Rifampin treatment and negative Chest X-ray within one year of placement
                              • See attached flow chart for your particular situation. 
                          • Proof of tetanus immunization
                          • Proof of Varicella or titer value report
                          • Proof of two MMR immunization or titer value report
                          • Proof of three Hepatitis B immunization or titer value report
                      • (4417 Preceptorship Only) Submit a front and back copy of your current health insurance card

                      Northside Atlanta Parking

                      Document Checklist

                      • Northside Hospital Health History Form  (2 pages)
                      • Acknowledgement and Release Form for Participation in Clinical Training Program (1 page)
                      • Confidentiality/Security of Information and Computer Access Code Agreement (1 page)
                      • Immunizations (listed above)
                      • Front and back copy of your current CPR Card
                      • (4417 Preceptorship only) Front and back copy of your current Health Insurance Card
                    • Student Information

                      Go to www.piedmont.org/studentorientation and complete the online application:

                      1. Read #4 Orientation Materials
                      2. Read and Complete #5 Student Participation Agreement
                        • School Name: Kennesaw State University
                        • Piedmont Facility: Enter Location Assigned
                        • Don’t Complete Faculty Information
                        • Student Name: Print your name
                        • Signature: Your Signature
                        • Date: Todays Date
                      3. Complete one of the following applications #6
                        • New Student: Applying for their first rotation within Piedmont Healthcare
                        • Returning Student: Student was cleared and has completed at least one rotation at Piedmont Healthcare location
                        • Employee: Student is a current Piedmont Healthcare employee
                      BEFORE YOU CLICK “SUBMIT” PRINT A COPY OF THE APPLICATION AND SUBMIT TO Jeannette Clarke

                      Completing The Application

                      Complete all fields of the application

                      • Enter your personal information
                      • School Name: Kennesaw State University
                      • Rotation Start & End Date: Receive information from Laura Allen E-mail
                      • School Representative First Name: Lillian
                      • School Representative Last Name: Valdez
                      • School Representative Phone Number: 470-578-2890
                      • School Representative E-mail Address: jclar276@kennesaw.edu
                      • Piedmont Entity: Select Assigned Hospital
                      • Select Floor: Other (bottom) If other: Med Surg
                      • Number of clinical hours: 3209 (36 hrs) 3313 (96 hrs) 4417 (172 hrs)
                      • Piedmont Coordinator Information:
                      • Student will be supervised by: Piedmont Employee
                      • AHA BLS Certification Expiration Date: Do not select N/A Enter Renewal Date from Current CPR Card
                      • Personal Health Insurance: Yes
                      • Professional Liability: COI Provided by School
                      • Online Orientation Material Reviewed: Yes (see #1 above)
                      • Complete all of the immunization information from your current physical
                      • Health screen requirements must be met prior to participation. Submit updated Piedmont required health documents to Immunitrax or room 3004 if you do not use Immunitrax.

                       

                      4. Must have flu vaccine for fall and spring for current flu season.

                      Take your flu documentation with you the first day of clinical rotation and your preceptor will take you to employee health to receive a flu vaccine sticker to wear during your clinical.

                      5. Log into your Advantage account and select Piedmont to view your drug and background results

                      6. Submit a front and back copy of your CPR card (Mountainside ONLY)

                      7. Parking at Piedmont Atlanta parking is offered at 1 Collier Road.  Enter the parking area from Collier Road (red arrow at left). Enter 1938* at the entry gate key pad and park in the lot. Enter the hospital via the Outpatient Diagnostic Center Entrance, the McDonnell Surgical Center Entrance, or the Main Entrance off Peachtree Road.

                      8. Submit a copy of the application and Student Participation Agreement to Jeannette Clarke

                      Document Checklist

                      • Application (Submit online REMINDER: Before submitting application print a copy and submit to room HS 3004)
                      • Student Participation Agreement (Submit to Room HS 3004)
                      • Flu documentation
                      • Front and back copy of CPR Card (Mountain Side Only)
                    • Student Information

                      Contact course coordinator about the form before submitting it.

                      • Fill out the Student Application
                      • Submit a current background check (can be done at county police department, for a fee. Contact course coordinator for additional information)
                      • Submit a current TB skin test
                    • Student Information

                      • No special requirements.
                    • Student Information

                      • Read the Student Packet
                      • Take the Student Test and submit the answer sheet to room HS 3004
                      • Redmond requires your social security number. Write your social security number in “ID number” line provided on your answer sheet, do not include any dashes. (e.g. 254875896)
                      • Complete the Confidentiality Statement and submit
                      • All students and instructors entering Redmond MUST sign in at the switchboard with a time in and the anticipated number of hours that they will be there.
                    • Student Information

                      Document Checklist

                      • Orientation workbook post test
                      • Dress code acknowledgement form
                      • HIPAA Training Manual Agreement
                      • Confidentiality Agreement
                      • Key form
                      • Personnel Record
                      • Parking Permit form
                    • Student Information

                      1. Read and complete the Student Information Packet
                      2. Complete Notice Regarding Background Investigation (1 page)
                        • Complete entire form
                      3. Complete Volunteers & Students/Interns Health History and Screening (3 pages)
                        • Complete top portion
                        • Complete Immunization History
                          • Tetanus Toxoid: Tetanus/Diphtheria/Pertussis (Tdap) from physical
                          • Measles/Mumps/Rubella: 1st MMR date from your physical or titer date
                          • Hepatitis B: 1st Hepatitis date form your physical or titer date
                          • Influenza: Influenza date for current year
                        • Have you had the disease: check yes or no and sign your name
                        • System Review: Check yes or no and explain all of “yes” answers and sign your name
                      4. Complete Medication Form (1 Page)
                        • List all Medication, if you have none to be listed write N/A on the first line.  Sign and Date
                      5. Forms to take to your Employee Health appointment: Authorization or Refusal for Recombivax-HB Vaccine, Tuberculosis Screening, TST signature page
                      6. Students MUST:
                        • Contact Glenn Prescott three weeks prior to clinical start date at 404-350-7340 to Establish your security Access log-in
                        • Contact Dot Jones three weeks prior to clinical start date at 404-350-7630 to schedule
                          • Physical
                          • Drug Screening
                          • Background Check - Bring Current Driver’s License & Social Security Card to appointment - At no charge to the student!

                      You will not be allowed to start clinical until you are cleared by Employee Health at Shepherd’s.

                      Medical Documents
                      (must be submitted with your clinical paperwork)

                      1. Front and back copy of your current cpr card
                      2. Immunizations
                        • PPD (Provide one of the following):
                          • Negative PPD: Negative ppd within 90 days  
                            • If your PPD is older than 90 days you must have another PPD done and submitted with your clinical paperwork
                            • Contact your health care provider or KSU clinic at 470-578-6644. The cost is $5.00.
                          • Positive PPD: Chest X-ray or radiology report within the last 12 months
                          • Quantiferon: Must be negative result
                        • Proof of tetanus immunization
                        • Proof of Varicella or titer value report
                        • Proof of two MMR immunization or titer value report
                        • Proof of three Hepatitis B immunization or titer value report
                        • Proof of Flu Immunization for current year

                      Document Checklist

                      • Notice Regarding Background Investigation (1 Page)
                      • Volunteers & Students/Interns Health History and Screening (3 Pages)
                      • Medication Form (1 Page)
                      • Medical documents (listed above)
                      • Front and back copy of your current CPR Card
                    • Student Information

                      1. Read and complete the Student Information Packet
                      2. Complete Notice Regarding Background Investigation (1 page)
                        • Complete entire form
                      3. Complete Volunteers & Students/Interns Health History and Screening (3 pages)
                        • Complete top portion
                        • Complete Immunization History
                          • Tetanus Toxoid: Tetanus/Diphtheria/Pertussis (Tdap) from physical
                          • Measles/Mumps/Rubella: 1st MMR date from your physical or titer date
                          • Hepatitis B: 1st Hepatitis date form your physical or titer date
                          • Influenza: Influenza date for current year
                        • Have you had the disease: check yes or no and sign your name
                        • System Review: Check yes or no and explain all of “yes” answers and sign your name
                      4. Complete Medication Form (1 Page)
                        • List all Medication, if you have none to be listed write N/A on the first line.  Sign and Date
                      5. Forms to take to your Employee Health appointment: Authorization or Refusal for Recombivax-HB Vaccine, Tuberculosis Screening, TST signature page
                      6. Students MUST:
                        • Contact Glenn Prescott three weeks prior to clinical start date at 404-350-7340 to Establish your security Access log-in
                        • Contact Shenita Ellis three weeks prior to clinical start date at 404-350-7586 to schedule
                          • Physical
                          • Drug Screening
                          • Background Check - Bring Current Driver’s License & Social Security Card to appointment -  At no charge to the student!

                      You will not be allowed to start clinical until you are cleared by Employee Health at Shepherd’s.

                      Medical Documents
                      (must be submitted with your clinical paperwork)

                      1. Front and back copy of your current cpr card
                      2. Immunizations
                        •  PPD (Provide one of the following):
                          • Negative PPD: Negative ppd within 90 days  
                            • If your PPD is older than 90 days you must have another PPD done and submitted with your clinical paperwork
                            • Contact your health care provider or KSU clinic at 470-578-6644 the cost is $5.00
                          • Positive PPD: Chest X-ray or radiology report within the last 12 months
                          • Quantiferon: Must be negative result
                        • Proof of tetanus immunization
                        • Proof of Varicella or titer value report
                        • Proof of two MMR immunization or titer value report
                        • Proof of three Hepatitis B immunization or titer value report
                        • Proof of Flu Immunization for current year

                      Document Checklist

                      • Notice Regarding Background Investigation (1 Page)
                      • Volunteers & Students/Interns Health History and Screening (3 Pages)
                      • Medication Form (1 Page)
                      • Medical documents (listed above)
                      • Front and back copy of your current CPR Card
                    • See Above - Emory Midtown / Emory University / St. Joseph's Hospital / Winship Cancer Center

                    • Student Information

                      • Review packet
                      • Complete and sign forms and return to Room 3004.
                    • Student Information

                      • Clinical paperwork will be completed at the clinical site.
                    • Student Information

                      *when signing up with ACEMAPP only use your KSU e-mail.

                      As of Fall 2017, WellStar is transitioning to ACEMAPP. You will receive an e-mail invitation to join this credentialing tool (KSU e-mail address) about one week after you are notified of your placement. If you do not receive this invitation please contact nu_medrecords@kennesaw.edu. The required documents will be in ACEMAPP and the deadlines for completion will be listed on the ACEMAPP site.

                      acemapp customer service info
                      1. Review the Infectious Disease Preparedness Protocol  - Healthcare Worker Travel Screening
                      2. 4412 & 4417 (only) Please note students must obtain a badge prior to 1st clinical rotation.  Contact Kennestone Security at 770-793-7780 to make sure it is ready for pickup.  Other WellStar Hospital Security Departments also prepare badges and if you are working at one of these facilities you may be able to pick your badge up there.  Students in other clinical groups – your Instructor will pick up your badges for you.
                      3. Students must bring a copy of their proof of flu vaccination to WellStar Security for badge pickup. 
                      • WellStar Atlanta Medical Center Security
                        • Step 1: Room 315 building 1st floor
                        • Step 2: Parking office 340 building 3rd floor
                      • WellStar Kennestone Security
                        770-793-7780

                      • WellStar Cobb Security
                        770-732-3990

                      • WellStar Douglas Security
                        770-920-6261

                      • WellStar Paulding Security
                        770-505-7168

                      • WellStar Windy Hill Security
                        770-644-1155

                      Professional Appearance

                      1. Check with your unit to see if they have any specific dress requirements
                      2. WellStar badges must be worn at all times while on campus
                      3. Artificial nails cannot be worn by employees providing patient care and/or the processing and management of patient care equipment, medical or food. Artificial nails include any substance or device applied to natural nails to augment or enhance nails. They include, but are not limited to, bonding, overlays, inlays, wraps, tips and/or attached decorations
                      4. WellStar nurses are identified by wearing navy blue. Students will wear their school uniforms

                      Site and Unit Specific Information

                      In addition to the WellStar prerequisite requirements, some units provide specific instructions to facilitate a positive student experience for all

                      Kennestone – park in the employee parking garage off of North Ave
                      Douglas – park in the employee lot or around the A-D buildings located behind the hospital (no parking in front of the hospital or the emergency room parking area)
                      Windy Hill – park in employee parking in the rear of the hospital (please do not park in the front of the hospital)
                      Cobb – park behind the hospital north of the Children’s Nest off Hospital Drive West

                      Thank you and we look forward to your clinical time at WellStar!

                     

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