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This is an opportunity for you to let us know a bit about yourself and also to acknowledge your understanding of our policies and procedures as they apply to students. Welcome!
1.
Four digit year currently (e.g., 2001)...........
2.
Two digit month currently (e.g., 03 for March....
3.
Four digit year I will graduate med. school......
4.
Name of medical school from which I am visiting..
5.
My last name.....................................
6.
My first name....................................
7.
My email address.................................
8.
My cell phone number.............................
9.
Phone number of a close family member............
10.
Number of weeks I plan to be at this hospital....
11.
I read & understand HIPAA confidentiality rules(Y/N)
a. yes     b. no
12.
I read & understand chaparone rules............(Y/N)
a. yes     b. no
13.
I read & understand rules on procedures........(Y/N)
a. yes     b. no
14.
I read & understand chain of command ..........(Y/N)
a. yes     b. no
15.
I read & understand attendance rules...........(Y/N)
a. yes     b. no
16.
I will complete a required self-evaluation.....(Y/N)
a. yes     b. no
17.
I will complete evaluation of res. & faculty...(Y/N)
a. yes     b. no
18.
Comments (optional - then click 'submit' below)