Connecticut Children's Clinical Placements

Thank you for your interest in becoming a student at our great organization. Please complete the form below and submit all required documentation. All applications will be reviewed and responded to promptly.

Dear Prospective Student,

Congratulations! We have been informed that you have been offered a clinical placement with Connecticut Children’s, a nationally-recognized not-for-profit hospital consistently named among the best in the nation for several of its pediatric specialties.


You will be working with a team of professionals dedicated to improving the physical and emotional health of children through family-centered care. Before you can begin, there are several items that will need your attention. Please use this as a checklist to ensure all requirements are met prior to your start date.

Contact Information

Please enter a preferred contact number here.

Please enter a preferred e-mail address.

Please specify whether you are currently employed with CT Children's in any capacity.

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Placement Information

If your anticipated start date is unknown, please provide your best estimate. Our Connecticut Children's team will update as needed.

If your anticipated end date is unknown, please provide your best estimate. Our Connecticut Children's team will update as needed.

Please choose the name of your school/university here. If you do not see your school's name here, please select "I Do Not See My Institution Listed".

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Please enter the first and last names of your school coordinator here.

Please enter your school coordinator's e-mail address here.

Please choose your degree program from the following options.

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Please choose the name of the department where you will be rotating from the following options.

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Please include the name of your CT Children's on-site preceptor. If you do not yet know the name of your preceptor, please leave this space blank.

Do you anticipate you will be conducting any research over the course of your placement with CT Children's?

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Immunization Information

All students are required to provide proof of health screening before beginning any clinical experience at Connecticut Children’s and affiliated companies. Records for the following should be kept on file in the student’s academic institution health office or personal physician’s office.

By checking the box below, you verify that the student's health screening information is accurate, all necessary vaccinations are current, and that a copy of the information is kept on file by the institution.

During the months of October through the following March, the seasonal Influenza vaccine is mandatory. If unable to receive influenza vaccine, a physician-documented declination form must be submitted.

Welcome Documents


Please carefully review the following documents. You may print these documents for personal reference.


Please sign the Code of Conduct Policy and Protection of Confidential Information Policy included in the Policies link below, and attach to the bottom of this form in the File Upload section.


1) Student Guide


2) CT Children's Policies


3) Patient Bill of Rights

Policy Review


By checking the boxes below, you attest to reviewing all of the required policies above.

I have reviewed the above policies carefully and have received answers to any questions I have concerning the expectations in these Policies as they apply to me. I agree to comply with these Connecticut Children’s policies, including: Code of Conduct Policy, Protection of Confidential Information Policy, Acceptable Use Policy, Workplace Attire Policy and Student Placement Policy.

Other Required Documentation

Please complete, attach, and upload the following required documents at the bottom of this form:


1. Background Check Attestation Form. This form indicates completion of an background check conducted independently by the learner's institution.


2. Physical Exam. Please submit results of a physical examination conducted within two years of the learner's intended start-date.

     

3. Proof of Influenza Vaccination*. You will be required to provide proof of influenza vaccination if your placement falls between the months of October and March.


4. Badge Photo.Your photo must be submitted with this form application. The Badging Office does not accept email attachments. For photo guidelines and specifications, see Badging Photo Process.

You may upload the following documentation here:


1) Health Screening Information Attestation

2) Background Check Attestation Form

3) Physical Exam Results

4) Proof of Influenza Vaccination (October - March)

5) Signed Confidentiality Agreement Form

6) Signed Code of Conduct Policy Form

7) Badging Photo


Any documentation not uploaded through this form can be submitted to studentplacements@connecticutchildrens.org


Thank you!

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