Clinical Confirmation Form

School name
Your name
Your phone number
Your e-mail address
Course name
Instructor's name
Start date
Site preference (if any)
Department
Clinical Focus (Rehab only)
Add course name
Course number
Clinical group number
Names of students
I verify this to be true	The students and faculty listed here are in compliance with the contractual health policies of the Clinical Education Setting including, but not limited to, certifying that each has received, prior to reporting to the Clinical Education Setting, a physical exam, are free from communicable disease, including tuberculosis (as documented by a negative skin test or negative chest x-ray, dated after skin test conversion, and are free from signs and symptoms of tuberculosis); have documented immunity to Rubella, Rubeolla, Mumps (MMR), and Varicella (positive titer) or shown evidence of immunization which meets ACIP definition of immunity (reported history of Chicken Pox is acceptable for Varicella immunity); have been advised of the risks of hepatitis and have either signed a waiver or have begun the Hepatitis B vaccination series or in the alternative, have completed the appropriate declination of immunization form, notice of which is provided to the Clinical Education Setting and have received the seasonal influenza vaccine within the last 12 months or completed and signed a declination form, notice of which is provided to the Clinical Education Setting.
I verify this to be true	The faculty and students listed have had a background check performed under the direction of the Institution in accordance with applicable law and according to the Clinical Affiliation Agreement.
Certifications	The faculty and students listed are certified in American Heart Association or Red Cross, Health Care Provider Basic Life, and have attended Iowa Department of Public Health approved Mandatory Reporter.
	DISCLAIMER - "Schools may be requested to provide evidence that these requirements have been met."