Clinical Student Placement Request Form

School OAR Attestation Document: Attach an “OAR Attestation or Summary Document” that lists or outlines the student drug screenings, background check, BLS, medical immunization records, HIPAA and clinical training conducted by the school/university that comply with OAR 409-030-0150 or attach individual student records. if an attestation document is not used by your organization. OHSU Hillsboro Medical Center expects school programs to adhere to the standardized administrative requirements established under Oregon Administrative Rules (OAR) 409-030-0150. Per the school affiliation agreement, OHSU Hillsboro Medical Center may request records for auditing purposes

Complete the student placement request for EACH student.

Date of Form Completion

mm/dd/yyyy

Student Legal First

Student Legal Middle Initial

Student Legal Last Name

Student Preferred Name (If name is different)

Student Date of Birth (MM/DD/YYYY)

Student Last 4 digits of SSN#

Student Primary Email

Student Permanent Address, City, State, Zip

Student Primary Phone

Student Emergency Contact

Student Emergency Contact Phone Number

Clinical Placement Start Date

Clinical Placement End Date

School Program/College/University Name

Total Clinical Hours Required

Current HMC Employee

Clinical Placement Department Requested

Inpatient Department

Ambulatory Department

Outpatient Clinic

Other location not listed above

Preceptor Selected If Known

Yes

TTS or Disability Required

Yes

EPIC Access Requested?

Yes - Full Epic Access (Ability to document) - Class Required

Yes - View Only - Online Training

Yes - OHSU/HMC Employee or Student Additional Access Needed

No - EPIC Not Requested

Will your role required medication administration?

Yes - Pyxis requested (required online training)

No - no training needed

Have you received your annual flu vaccine?

Have you received a COVID 19 vaccine?

School OAR Attestation

By clicking the box below, I attest this student meets the Oregon Health Authority Health Profession Student Clinical Training Administrative requirements (OAR) 409-030-0150 as required by Hillsboro Medical Center's affiliation agreement. Click for further details: https://secure.sos.state.or.us/oard/displayDivisionRules.action?selectedDivision=1662

Program Coordinator Name

Program Coordinator Phone Number

Program Coordinator Email

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