I Verify the Following Students, Faculty, And/Or Residents

Affiliation Verification Form

School: Choose School / If other, please list: Enter text.
School or residency affiliation documents on file: Yes ☐ / From: Enter text. / To: Enter text.
Educational/Clinical or Residency Program: Enter text.
Facility: Choose a Facility / If other, please list: Enter text.
Department: Enter text.
Dates of Experience - From: Enter text. / To: Enter text.
Number of hours each student or resident is required to complete: Enter text.
College Clinical or Residency Program Contact Name: Enter text.
College Clinical or Residency Program Contact’s Phone Number with Area Code: Enter text.
College Clinical or Residency Program Contact’s Email: Enter text.

I verify the following students, faculty, and/or residents:

1. ☐ Complied with the provisions of the Wisconsin Caregiver Background Check Law (Wisconsin Administrative Code, Chapter HFS 12). Education institute has completed or initiated the Wisconsin Caregiver Background Check and the following are not barred from providing services under Chapter HFS 12. Students or residents with a criminal record are forwarded to the Human Resource Management/People Services Director for review and approval prior to beginning the clinical training.

2. ☐ Have met the health requirements as required by the school/residency program and facility. At a minimum:

ü Hepatitis B series, positive titer or a declination stating they do not want the series.

ü 2 MMR vaccines or a positive rubella, rubeola, and mumps titer.

ü Baseline TB screening using two-step TB skin test or single blood assay test (ex. QuantiFERON). Annual single TB skin test or blood assay test thereafter.

ü A record of one-time dose of Tdap; and tetanus vaccine within the last 10 years.

ü Two varicella vaccination dates or a positive varicella titer.

3. ☐ Have received the flu vaccine for the current season by November 1. By checking this requirement, the school or residency program agrees to have the student or resident’s flu vaccine validation on file. The flu vaccine is required for clinicals/residency programs from October 31 to March 31. If you have a student or resident who declines the flu vaccine, you will need to contact the clinical or rotation site to verify their declination process.

4. ☐ Satisfactorily completed the following five mandatory modules.

a) Infection Control, Bloodborne Pathogens and Isolation Precautions

b) HIPAA Confidentiality and Compliance Orientation

c) Patient and Caregiver Safety

d) Professional Expectations in the Workplace

e) Clinical/Rotation Skill Awareness and Validation

5. ☐ Signed the confidentiality agreement and acknowledgement of completion of mandatory requirement modules.

6. ☐ Successfully completed CPR training in the last two years. OR ☐ Do not have direct patient care responsibilities.

7. ☐ Have a current, valid Wisconsin license. OR ☐ Do not require a license for this experience.

Names of Students, Faculty, or Residents:

Name & Title of Authorized Person: Enter text.
Date: Enter a date.

Please return this form to the clinical/residency education coordinator of the clinical/rotation site.

Thank you!

Page 1 of 2 GGBHA Affiliation Verification Form Updated 8/29/2017