Inpatient and Ambulatory - Woodland Hills

1. Request for Clinical Rotation Form
   To begin the clinical request process, the school must fill-out and submit the Request for Clinical Rotation Form to the Inpatient or Ambulatory Academic Liaison of Kaiser Woodland Hills as applicable. This form must be submitted at least 8 weeks prior to the clinical rotation start date.

2. NUID & HealthConnect Access Request Form
   Due: at least 4 weeks prior to the clinical rotation start date. Please note: it takes 4 weeks to secure HealthConnect access for students. If the NUID & HealthConnect Access Request Form is not submitted on time, then the school's clinical rotation will be denied.

3. Pre-Clinical Paperwork
   Due: at least 2 weeks prior to clinical rotation start date. If the pre-clinical clearance forms are not submitted on time, then the school's clinical rotation will be delayed. Please email all paperwork as one packet; items will not be accepted piece-mailed.

   1. Copy (back and front) of current LA City Fire Card for each student

   2. Copy (back and front) of current American Heart Association BLS card for each student

   3. Copy (back and front) of valid license for clinical instructor and post-licensure students

   4. Orientation Verification Form (completed and signed by school)

   5. Health and Safety Verification Form completed and signed by your school; please indicate all dates on the form; the school's signature indicates that the information is accurate. Please do not submit additional proof of immunization aside from this form.
      

      • TB testing: 1 PPD in last 2 years and 1 PPD in last 12 months; or chest x-ray within 1 year

      • Hepatitis B (3 vaccination dates)

      • Varicella (2 vaccination dates or 1 titer date)

      • MMR (2 vaccination dates)

      • Tdap (1 vaccination date; within 10 years)

      • If declining the Influenza, Hepatitis B, or Tdap vaccinations, please submit the appropriate declination forms which can be found in the Health Screen and Other Forms section.

   6. Interval Health Evaluation Questionnaire Form

   7. Child Abuse Reporting Form

   8. Elder Abuse and Dependent Adult Abuse Reporting Form
      

   9. Drug-Free Workplace Form
      

   10. Confidentiality Agreement Form
       

   11. Compliance/HIPAA Form
       

   12. Health Connect Confidentiality Nondisclosure Form
       

   13. ID Badge Request Form for Kaiser Woodland Hills
       

   14. Annual Mandatory Update Training Attestation Form

4. Annual Mandatory Update Training

   • Training

   • Attestation Form

5. ID Badge Request Form for Kaiser Woodland Hills

• ID Badge
  See the Academic Liaison for approval prior to requesting your badge

6. Medical Center Map for Kaiser Woodland Hills

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