College & Residency Program Coordinators

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STEP 1:  Complete the Clinical/Residency Placement Request Process

1. You must have a current contract/affiliation agreement with the healthcare organization to proceed.  Please check with your school/residency program reps to confirm whether or not your school/residency program has a current affiliation agreement with the healthcare organization.
2. Complete the clinical/residency program placement request form (see below). This Excel form has two sheets; 1) Preceptor Requests, 2) Groups with Instructors.
3. For preceptorships, requests should be submitted 10-12 weeks before the clinical start date.
4. If you haven’t heard back in a reasonable amount of time, please contact the facility representative directly.
5. Email the completed form to the contact person listed on the ‘Contacts’ link below.
6. If approved, continue to Step 2.
7. If denied, the facility will contact you.

STEP 2:  Complete the Clinical/Residency Program Placement Process (after you receive approval)

1. Complete and submit the affiliation verification form (see below) to the clinical/rotation site. Form is to be submitted on or by the clinical/residency program start date and no more than two weeks before the clinical/residency program start date.
2. After all of the modules below are completed, maintain in the school files the signed/dated confidentiality agreement and acknowledgement of orientation modules (see below). (For Residents: Click the ‘Residents’ tab under the ‘Clinicals/Rotations’ drop-down menu for their learning modules and confidentiality agreement, etc.)
3. Contact the clinical/rotation site to insure computer access and training.

STEP 3: Faculty should submit the student completed ‘Student Evaluation of the Clinical Site OR Precepted Clinical’ forms to the healthcare facility’s clinical site coordinator no later than TWO WEEKS after completion of the clinical. (Resident coordinators: See ‘Residents’ webpage for ‘Evaluation of Rotation Site’ form to be completed by residents.)

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Prior to working at a clinical site, the following Orientation Modules must be completed annually by students/residents/faculty members. After completing all four modules and you understand the information presented, complete, sign, and submit to your school or faculty member the ‘Confidentiality Agreement and Acknowledgement of Orientation Learning Modules‘ form. The school will retain the signed/dated forms. Do not submit the forms to the healthcare facility.

ORIENTATION MODULES 1-4:

1. HIPAA Privacy & Security – New 6/26/2020
2. Infection Prevention – New 5/22/2020
3. Professional Expectations in the Workplace – New 5/22/2020
4. Safety in the Workplace – New 5/11/2020

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Affiliation Verification Updated 7/2/2019 Background Approval Policy Updated 1/25/2019 Criminal Background Check Process Added 1/25/2019 Clinical Placement Request Forms Reviewed & Updated 5/11/2018 Sheet 1:  Preceptor Requests Sheet 2:  Groups with Instructors Confidentiality Agreement and Acknowledgement of Orientation Modules – Updated 6/26/2020

CONTACTS Contacts –  Utilize the Excel workbook tabs to access specific contact groups. Updated 8/31/2020 Contacts (College/University) for Important & Time Sensitive Communications from GGBHA Clinical Sites – Updated 9/26/2019 – When emailing this contact group, please use “IMPORTANT & TIME SENSITIVE COMMUNICATIONS FROM CLINICAL SITE” in the subject line. Set the email priority as “High Importance”.

CPR & CPR Renewal – American Heart Association BLS training must be completed within the last two years. Heartsaver and online-only training without a classroom skills component are not acceptable.

EPIC Epic Access Request Updated 10/25/2019 – Listed below are emails where Epic access requests can be sent. For Aurora, please use their new ‘Aurora Epic Request’ form linked below. ADVOCATE AURORA HEALTH CARE Aurora Epic Request – New 7/21/2020 Laura Janssen (Inpatient Requests) laura.janssen@aah.org Carrie Lemke (Medical Group Epic Requests & Affiliation Forms) carrie.lemke@aah.org BELLIN isaccess@bellin.org – Pyxis and glucose monitor requests also need to be requested at the same time and are included on the Epic email. Pyxis: Pyxis.Pharmacy@bellin.org  Glucose Monitor: Mindy.mayo@bellin.org HSHS Epic Access, Help Desk – helpdesk@hshs.org Gaining Epic Access at HSHS 10/26/2017 Epic: Student Modules & E-Learnings – PLEASE NOTE: These files require a password to open. User IDs and passwords can be obtained from Laura Janssen (not Karen Ganey as indicated on Aurora’s website). Epic Trained Instructors Updated 3/10/2020

Hepatitis B Declination Updated 12/14/2018 (Resident coordinators see ‘Residents’ webpage.) Instructor Preclinical Checklist Updated 5/24/2019 Onsite Student/Resident Orientation Checklist Updated 11/22/2019

PRECEPTOR INFORMATION RN Preceptor Handbook Updated 1/25/2019 Preceptor Agreement Updated 5/24/2019 Course Evaluation (To be Completed by the Preceptor) Updated 8/29/2017

STUDENT ASSIGNMENTS Bellin College NWTC Rasmussen College UW Green Bay

Student Evaluation of the Clinical Site OR Precepted Clinical Updated 5/24/2019 – At the completion of a clinical experience, students are to complete this form and return it to their college or university instructor.  Faculty should submit the completed “Student Evaluation of the Clinical Site OR Precepted Clinical” forms to the healthcare facility’s clinical site coordinator no later than TWO WEEKS after completion of the clinical. (Resident coordinators see ‘Residents’ webpage for ‘Evaluation of Rotation Site’ form to be completed by residents.) Student Immunization & Health Requirements – Updated 12/14/2018 (Resident coordinators see ‘Residents’ webpage.)