Student Forms

Today's Date *

Name: *

Housecalls

I understand that by electing to attend clinicals in this practice I will potentially be exposed to patients with communicable diseases including COVID19 *

Yes

Please indicate your status below: *

I am participating in my University's weekly COVID testing

I have not been notified of a positive COVID test

I am a Registered Nurse in the state of Ohio and as such am knowledgeable in how to recognize signs and symptoms of communicable diseases, how to follow clinical practice guidelines, how to properly don and doff personal protective equipment (PPE), and practice appropriate caution/ implement appropriate safeguards during contact with others in both my personal and professional daily life

I have not had any close sustained contact while not wearing PPE with anyone who has had a positive COVID test in the last 14 days

I am not experiencing any signs or symptoms of COVID 19 as delineated by the Centers for Disease Control and prevention (CDC)

I understand that if all of the above conditions are not met that I will not be permitted to attend clinical in this practice *

Yes

Clinical Attestation Form