Healthcare Clinical Rotation Form

Healthcare Clinical Rotation Form

Student Name:    Date of Birth:    Student ID:

Student Information

Rotation Assignment Details

Rotation Start Date:    Rotation End Date:    Rotation Type:

Insurance & Professional Liability

I carry personal professional liability insurance: Yes No

Immunizations & Health Requirements

Tuberculosis (TB) Screening Date:    Result: Negative Positive

Background Check & Compliance

I authorize release of criminal background check, drug screening, and immunization records to the clinical site and my educational institution as required for placement.

Background check completed: Yes No    Date of clearance (if applicable):

Confidentiality, Conduct & Acknowledgments

By signing this form I acknowledge and agree that: I will maintain all patient information in strict confidence in accordance with applicable privacy laws and clinical site policies; I will not access or disclose protected health information except as required for patient care and education; I will complete required privacy and safety training prior to beginning the rotation.

I understand that failure to comply with confidentiality, safety, immunization, or site-specific requirements may result in suspension or removal from the rotation, and I accept responsibility for any professional or academic consequences arising from such noncompliance.

I hereby authorize the exchange of immunization, background check, and certification information between the educational institution and the clinical site for the duration of this placement. Authorization expiration date:

Emergency Contact

Certification by Student

I certify that the information provided on this form is true and complete to the best of my knowledge. I understand that knowingly providing false information or omitting material facts may be grounds for removal from the clinical rotation and may subject me to disciplinary action by my educational institution.

I agree to comply with all clinical site policies, safety protocols, and supervisory directions. I accept responsibility for my transportation, professional conduct, and reporting any exposure incidents or safety events immediately to the clinical preceptor and my educational program.

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