GUTHRIE: VISITING STUDENT ROTATION REQUEST FORM

GUTHRIE: VISITING STUDENT ROTATION REQUEST FORM

Welcome to Guthrie's Student Affairs Department. In order to initiate a non-medical student rotation request, the first step is to complete this form. The information you provide will help us to respond to your inquiry and process your request. PLEASE BE ADVISED THAT REQUESTED START DATE MUST BE AT LEAST 60 DAYS AFER THE DATE OF THE REQUEST.

Date of this Request:*

PLEASE NOTE THAT ROTATION REQUEST MUST BE SUBMITTED AT LEAST 60 DAYS PRIOR TO THE DATE OF THE ROTATION.

Student's Last Name:*

Student's First Name:*

Have You Had a Name Change?*

Please use the drop down menu to indicate Yes or No.

Select

If Yes, What was your previous name?

If you had a name change, please provide your previous name. This will help reactivate a prior account under another name.

Are You Currently A Guthrie Employee?*

Select

Are you a Returning Student?*

Please use the drop down menu to answer Yes or No.

Select

Have You Previously Had an EPIC Account at Guthrie*

Please use the drop down menu to answer Yes or No.

Select

Interested in Future Employment at Guthrie?*

If you are interested in a potential career at Guthrie, please let us know and this information will be shared with Guthrie recruitment.

Select

Student's Email Address:*

Help-Desk Security PIN Number*

Please provide a four-digit security code that will be used to confirm your identify.

Student's Phone Number:*

Phone

OBSERVER ONLY: Focus Area of Interest

Please identify the area you are interest in observing.

REMOTE ROTATION?*

Please let us know if the rotation request is for an on-site, hybrid, or remote only experience request.

Select

HIGH SCHOOL OBSERVER ONLY: Age Requirement

If you are a high school student requesting an observation/shadowing experience, please indicate your age range using the drop down menu options provided.

Select

HIGH SCHOOL OBSERVER ONLY: Name of School

If you are a high school student requesting an observation/shadowing experience, please provide the name of your school.

Name of School/Program:*

Please TYPE the name of your educational institution or select from the choice in the drop down menu.

Select or enter value

TYPE OF ROTATION REQUESTED:*

Please select one choice using the drop down menu.

Select or enter value

Type of Program:*

Please select from the drop down list or enter type of program if not listed. OBSERVERS - please select "Not Applicable - Observer" as your type of program.

Select or enter value

Educational Affiliate's Contact Email Address

Please provide the email address of the person at your school who should receive updates on this request. This often would be the clinical or educational coordinator for your program or the person responsible for affiliation agreements.

Observer or Clinical Student?

Select

PREVIOUS DOCUMENTED TRAINING: HAND-HYGIENE*

Do you have prior documented (you can produce documentation from your educational institution) hand-hygiene training?

Select

CURRICULUM REQUIRES OPERATING ROOM EXPERIENCE?*

Please indicate if your program curriculum requires an operating room experience.

Select

CURRICULUM REQUIREMENT DOCUMENTATION:

If you indicated that an operating room experience is required, please upload information to demonstrate that requirement.

Drag and drop files here or

IF OR EXPERIENCE REQUIRED - TYPE?*

Please use the drop down menu to identify the type of OR experience required. The level of pre-OR education will be driven by your response.

Select

Academic Year*

Please use the drop down menu to identify the academic year this request will take place in.

Select

Semester*

Please use the drop down menu to identify the semester of this requested rotation.

Select

START DATE REQUESTED:*

Requested START DATES less than 30 days before request date will be denied. Effective 7/1/2023, requests less than 60 days before the request date will be denied. Time is needed to review the status of the current agreements, distribute an onboarding checklist, and clear the student before the start date.

Requested Rotation End Date:*

OBSERVERS ONLY: Number of Hours Observing Daily for Period Requested

Rotation Site:*

Please identify the primary Guthrie Entity that you are requesting to rotate with. Provide additional site specific information in the next box.

Select

Specific Site:

Please provide additional information about the specific site. If you selected a regional office, you might type in "Guthrie Southport Family Medicine."

GUTHRIE PRECEPTOR'S NAME:*

Please identify the Guthrie employee who has previously agreed to supervise your rotation experience. PLEASE TYPE THE NAME OF YOUR PRECEPTOR IN THE SPACE BELOW. If not identified prior to making this request please note that a preceptor has not been secured.

Preceptor's Email Address:

If known, please provide the email address of the preceptor who has agreed to supervise your rotation experience.

COVID VACCINATION STATUS:*

All employees, contractors, students, and volunteers of The Guthrie Clinic are recommended to be fully vaccinated for COVID-19. Please indicate COVID vaccination status using the drop down menu.

Fully Vaccinated

Fully Vaccinated Plus Boosters

1st Dose

Not Vaccinated

FLU VACCINATION STATUS*

If you are rotating between November 30th - May 31st, a flu vaccination is required. The New Innovations Onboarding Checklist will provide further information about making a request for an approved exemption if your request to rotate is approved.

Fully Vaccinated

Will Request Exemption

Send me a copy of my responses

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