Affiliate Student Placement Request, Roster and Compliance Log

2012PHC Affiliate Student Placement Request

Step 1: Please completePlacement Request information below

*Click inside the grey shaded fields or use the TAB key to maneuver to the next field*

Date: //

School/ Organization: Program Type (i.e. Nursing, Resp. Ther.)

Instructor’s Name: Contact Number: --

Email:Cell Phone: --

Site: WMH OMH CLINIC: OTHER:

Requested Unit (i.e. Med/Surg; OB): Number of students:

Clinical Dates: From: // To: //

Days: M T W Th F S Sun. Time of day: From: To:

(Please use Military Time)

Total hours* on site per student for this rotation:

(* To determine, calculate hours per day on site X number of days on site.)

Please note:The signature below (manual or electronic) indicates and verifies that all students and faculty have met requirements for placement at ProHealth Care and are in compliance with the affiliation agreement related to

• Caregiver Law and regulations as stipulated in Wis. Stats. HFS12 and HFS 13 Wis. Admin Code and associated DHFS rules and regulations.
• PHC Health Requirements
• OIG and GSA Governmental Database check

______

Electronic Signature and Title of School RepresentativeDate

Step 2: Please Complete Compliance Log (page 2)

Prior to their clinical, students must SIGNand DATE theCompliance Logon page 2. This document acknowledges that they have:

1. Completed the Student Orientation Module and Quiz
2. Read and Agree to the requirements of the ProHealth Care Student Workforce Confidentiality Agreement.
3. Students and Faculty have met requirements of the clinical affiliation agreement.

2012PHC Affiliate Student Compliance Log

Instructors

1. Once the studentshave completed the Student Orientation Module and Quiz, enter their names and their quizscore in Compliance Log(page 2).
2. Print out the Compliance Log and make sure the students signand date it.
3. Return signed Compliance Log to Monica Erdmann (address on page 2).

Fax to: 262-928-2092

Mail to:Monica Erdmann

c/o PHC Care Center for Learning and Innovation

725 American Avenue

Waukesha, WI 53188

Date: //

School/ Organization: Instructor’s Name:

Contact Number: --Email:

Experience Dates: From: // To: //

Questions? Please contact Monica Erdmann,

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