CHRISTUS St. Michael Rotation Request

(If this is a medical emergency, please call 911)

With our vision on education and community service, our goal at CHRISTUS St. Michael Health System continues to be assisting with the education process of future health care professionals. With a formal process in place, once we receive your request, we will determine if it meets the basic criteria for further consideration for a clinical rotation within CHRISTUS St. Michael Health System. We appreciate the opportunity to serve you, our customers, with your educational needs. Thank you for your interest in pursuing a clinical rotation with our facility.

Applicant Information

I am seeking an educational opportunity in the following area: Clinic Hospital Education Department First Name Last Name Student ID Licensed Independent Practitioner Request (No School Affiliation. State Reason for request here and complete remainder of application) Are you employed with CHRISTUS St. Michael? Email Address Mailing Address Address Line 2 City State Zip Code Phone Number Date of Birth Last 4 of SSN What encouraged you to select CHRISTUS St. Michael? Student Program Discipline

Institution Information

Institution Name (College, University or School) Address Address line 2 City State Zip Contact's First Name Contact's Last Name Contact's Email Contact's Phone Number Course Title Requiring Clinical Hours Semester and Year Applying For (only one at a time) Date desired to begin clinical Number of hours required Approximate end date of clinical Please list your top 2 objectives for seeking this clinical rotation: 1st Preceptor Name 1st Preceptor Title 1st Preceptor Clinic or Hospital Department 1st Preceptor Email 1st Preceptor Phone Number 2nd Preceptor Name 2nd Preceptor Title 2nd Preceptor Clinic or Hospital Department 2nd Preceptor Email 2nd Preceptor Phone Number Are you fully vaccinated for COVID-19? Yes No I have read and accept the requirements below

Requirements

As the student, I acknowledge I have satisfied the required immunizations, drug screen and criminal background check and my Institution has on record:

Immunizations: Hepatitis B, MMR, Varicella, Pertussis, TB Skin Test (or Chest X-Ray) Flu. One of the following: 1) Verification of immunization, 2) Request for Religious Exemption from Influenza Vaccination, or 3) Request for Medical Exemption from Influenza Vaccination. Drug Screen, Criminal Background Check

Additionally, I recognize while I am conducting my clinical rotation that I will be required to:

Wear my University Student Name Badge in full view identifying me as a student. If you do not have a current University Student Name Badge you must be sure to have one made through your University before starting your clinical rotation.

Wear any uniform approved by my university or contact my preceptor to determine what is acceptable in the clinical rotation practice. (Uniform scrubs or business attire only. Absolutely no jeans are allowed.)

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CHRISTUS St. Michael Rotation Request

Applicant Information

Institution Information

Requirements