Required Documentation
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Required Documentation
Documentation to the Student Placement Program
| Required Item | Student | Clinical Instructor | Notes | Submission |
|---|---|---|---|---|
| Valid Affiliation Agreement | X | Must be established and fully executed before requests can be processed. All communication to establish or amend agreements must occur between our Student Placement Department and the school’s coordinator. | Submitted to Department | |
| HIPAA Training Certificate | X | X | Complete the HIPAA Privacy & Information Security Training module (approximately 10 minutes). After finishing the module, follow the steps to receive your certificate. Students and Clinical instructors will need to create a Temporary ID. If you are student, please select “Visiting Student” for Affiliation. If you are a clinical instructor, please select “Visiting Student” for Affiliation. Must be signed by the student or instructor. | Submitted to Department |
| UCLA Health Confidentiality Form | X | X | For Department, please write: Nursing. Must be signed by the student or instructor. | Submitted to Department |
| Certificate for completed Annual Education Clinical Course | X | X | Complete the Annual Education Clinical Course module, complete the 35-question quiz. Follow the steps to receive your certificate of completion. Students and Clinical instructors will need to create a Temporary ID. If you are student, please select “Visiting Student” for Affiliation. If you are a clinical instructor, please select “Visiting Student” for Affiliation. | Submitted to Department |
| COVID-19 Proof of Vaccination or School Letter of Exemption | X | X | Full dose (either Moderna/Pfizer 2 doses or Johnson & Johnson 1 dose) + 1 booster dose | Submitted to Department |
| Current School ID Badge | X | X | Must be worn on student clinical days when on UCLA Health campus. Students and instructors do not receive a UCLA Health badge. | No submission required. Must wear when on-site for clinical days |
Documentation Kept on School File
| Required Item | Student | Clinical Instructor | Notes | Submission |
|---|---|---|---|---|
| Respiratory Fit Test | X | Must fulfill with UCLA Health to ensure proper fitting with current N95 mask supplies. Visit this page to see the schedule of available fit test dates. | Kept on file by School | |
| Department Specific Orientation Checklist | Student Specific | Instructor Specific | All students must complete the department-specific orientation within the first week of your clinical/practicum. Instructors must complete the department-specific orientation within the first week at UCLA campus only if student placement requires that you are on site. | Kept on file by School |
| Life & Safety Checklist | Student Specific | Instructor Specific | All students must complete life & safety checklist within the first week of your clinical/practicum. Instructors must complete life & safety checklist within the first week at UCLA campus only if student placement requires that you are on site. | Kept on file by School |
| Background Check | X | X | Livescan is not necessary | Kept on file by School |
| BLS Card | X | X | Current, unexpired card for Basic Life Support | Kept on file by School |
| Physical Examination | X | X | A medical provider must clear you as safe to practice your duties as a student nurse on-site | Kept on file by School |
| Immunization Records | X | X | See table below for specific requirements for immunizations for health clearance. | Kept on file by School |
Immunizations & Health Clearance
UCLA Health has specific requirements for immunizations in order to be placed on the units or in departments within the system.
Clinical instructors AND students must provide documentation to their school and the school must have this documentation available on request.
It is the school's responsibility to ensure that the instructors and students completing clinical hours at UCLA Health facilities are tested for and free of active tuberculosis (TB). To meet this requirement, a Quantiferon Gold or T-Spot, must be completed within three (3) months of a UCLA student placement assignment. Students with assignments that exceed 12 months, must be tested for TB annually and be free of active TB at all times.
**Waivers for immunizations are not permitted unless due to medical reasons.
Please see the Student Nurse Immunization Checklist for the required immunizations.
Documentation for Immunizations &
Health Clearance
| Required Item | Student | Clinical Instructor | Notes | Submission |
|---|---|---|---|---|
| COVID-19 Vaccination | X | X | Proof of COVID-19 Vaccination (Completed series plus booster) OR COVID-19 Vaccine Letter of Exemption (If the university or school has a COVID-19 exemption letter, we will accept that form.) Disease history of COVID-19 will not be accepted. | Kept on file by School |
| Influenza | X | X | Every year from November 1st until March 31st, healthcare personnel must either be vaccinated for influenza or wear a surgical mask when in direct contact with patients, providing direct patient service (within 6 feet), or in a patient room at Ronald Reagan UCLA Medical Center; UCLA Medical Center, Santa Monica; UCLA Resnick Neuropsychiatric Hospital; and UCLA West Valley Medical Center.** | Kept on file by School |
| Measles, Mumps, Rubella (MMR) | X | X | Medication documentation of two (2) doses of MMR vaccination OR Medical documentation of one (1) blood titers that indicate immunity to MMR Disease history of measles, mumps, and rubella will not be accepted | Kept on file by School |
| Tuberculosis Test (TB) | X | X | Medical documentation of a Negative QuantiFERON Gold (also known as t-spot) blood test in the last 12 months | Kept on file by School |
| Tetanus, Diphtheria, Pertussis Vaccine (TDaP) | X | X | Medical documentation of TDaP vaccination within the last 10 years OR Signed TDaP Declination is unable to provide medical documentation | Kept on file by School |
| Varicella | X | X | Medical documentation of two (2) doses of Varicella vaccination OR medical documentation of one (1) blood titer that indicate immunity to Varicella Disease history of Varicella will not be accepted. | Kept on file by School |
** Students and/or clinical instructors are not eligible to receive the free flu shot services provided by UCLA Health or redeem the CVS voucher. Flu vaccines must be received privately by the student and/or instructor. Students and/or clinical instructors may obtain a flu badge for the season through UCLA Health Occupational Health and present proof of flu vaccine.