MSN Nurse Anesthesia Clinical Requirement Packet
NAME: ____________________________ DATE: _________________
Students will not be allowed to start their clinical practicum without completing all clinical requirements. Copies of all of the requirements listed below MUST be placed in a 9x12 envelope, in the order listed, with this checklist attached to the outside. Submit this packet to Sara Wilson. The packet must be complete when submitted; if any requirements are omitted or out of sequence, the packet will be returned, and the student will not be admitted into clinical rotations until a complete packet is submitted.
_____ Photograph-Must be a clear headshot, approximately passport photo size, with only you in the photo.
Receipt(s) from the Bursar’s Office for the following fees:
_____ Malpractice Insurance (38.00)
_____ JACHO and HIPPA testing fee (5.00)
_____ Clinical ID Badge (8.50)
_____ UTC Student Health Center form completed in full and signed by Center staff -- UTC Student Health requires you to complete and bring them the Medical and Physical Health form before they can complete the Student Health Center form. You cannot be seen by the UTC Student Health Center unless you bring both the Student Health Center and Medical and Physical Health forms.
_____ Copy of health insurance card
_____ Copy of CPR card: ACLS, PALS
_____ Completed influenza vaccine form
_____ Signed confidentiality statement
_____ Signed information release form
_____ Signed background check policy
_____ Complete JACHO and HIPPA testing through TCPS
_____ Copy of current RN license
_____ Signed N95 Fit Test agreement form*
*Students must complete their Drug Screening and N95 Fit Test at Workforce Corporate Health at Erlanger Hospital. Students must have a permission letter from the School of Nursing when going to Workforce Corporate Health.
Questions? Email Sara Wilson or phone at 423-778-7760 or Email Sarah Blackburn or phone at 423-425-4750.
