College & Residency Program Coordinators

---

---

PRECLINICAL

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.)

---

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 health care facility.

ORIENTATION MODULES 1-4:

1. HIPAA Privacy & Security – Updated 2/26/2021
2. Infection Prevention – Updated 3/26/2021
3. Professional Expectations in the Workplace – Updated 2/26/2021
4. Safety in the Workplace – Updated 2/26/2021

---

PRECLINICAL FORMS

Affiliation Verification Updated 10/23/2020 Background Approval Policy Reviewed 10/23/2020 Criminal Background Check Process Reviewed 10/23/2020 Clinical Placement Request Forms Reviewed 10/23/2020 Sheet 1:  Preceptor Requests Sheet 2:  Groups with Instructors Confidentiality Agreement and Acknowledgement of Orientation Modules – Updated 10/23/2020 Hepatitis B Declination Reviewed 10/23/2020 Immunization & Health Requirements – Reviewed 10/23/2020 Instructor Preclinical Checklist Updated 10/23/2020

DURING CLINICAL FORMS

Onsite Student/Resident Orientation Checklist Updated 10/23/2020 COVID-19 Student-Faculty Communication Procedure – New 8/12/2020 STUDENT ASSIGNMENTS Bellin College – Updated 10/23/2020 NWTC – Updated 10/23/2020 Rasmussen College – Updated 10/23/2020 UW Green Bay – Updated 10/23/2020

POST CLINICAL FORMS

Student Evaluation of the Clinical Group OR Precepted Clinical Updated 10/23/2020 – 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.)

CPR, EPIC, PRECEPTOR INFO, CONTACTS

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 Site Training Handouts – Site Specific Training Sheets for ABMC, HSHS, Bellin – Added 2/3/2021 Epic & Pyxis Access Requests Updated 10/23/2020 – Listed below are emails where Epic access requests can be sent. For Aurora, please use their new ‘Advocate Aurora Epic/Pyxis Request Form’ linked below. Epic Trained Instructors Updated 4/30/2021 ADVOCATE AURORA HEALTH CARE Advocate Aurora Epic/Pyxis Request Form – Updated 10/23/2020 Laura Janssen (Inpatient Requests) laura.janssen@aah.org Any questions regarding undergraduate or graduate level clinic nursing students can be directed to: Karen Ganey, Nursing Professional Development Specialist Email: winursingclinicalaffiliations@aah.org 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). 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

PRECEPTOR INFORMATION RN Preceptor Handbook Updated 9/25/2020 Preceptor Agreement Updated 9/25/2020 Preceptor Evaluation of the Precepted Clinical Experience Updated 9/25/2020

CONTACTS Contacts –  Utilize the Excel workbook tabs to access specific contact groups. Updated 11/30/2020