UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
2D Medical Group
Barksdale AFB, Louisiana
4th Medical Group
Seymour Johnson AFB, North
Carolina
5th Medical Group-Minot AFB
Minot AFB, North Dakota
18th Medical Group, Kadena Air
Base
Japan
21st Medical Group, Peterson Air
Force Base
Colorado
35th Medical Group, Misawa AFB
Japan
99th Medical Group, Mike
O’Callaghan Federal Hospital
Nellis Air Force Base, Nevada
377th Medical Group, Kirtland AFB
New Mexico
509th Medical Group
Whiteman AFB, Missouri
673rd Medical Group, Join Base,
Elmendorf-Richardson
JBER, Alaska
MSN
MSN and DNP
Student must complete the Trainee Agreement
Addendum
Student must complete Trainee Addendum
Nurse Practitioner
Student must complete the Trainee Agreement
Addendum
Executive Nursing
Admin DNP ONLY
Executive Nursing Admin DNP ONLY
Advanced Practice
Student must complete Trainee Agreement
Addendum
Advanced Practice
Student must complete Trainee Agreement
Addendum
Student must complete Attachment 1
RN-BSN, MSN,
DNP
Student must complete and sign the Trainee
Agreement Addendum. While utilizing this
agreement, students are prohibited from engaging in
off-duty employment at USAF MTF.
Student must complete Trainee Agreement
Addendum
RN-BSN, MSN,
DNP
Attachment 1 and 2 for Trainee Agreement
Addendum
A
Access Community Health Care
Spring Hill, Florida
BSN, RN-BSN, MSN,
DNP
USA Faculty: Please contact the following person for
any students requesting this site. Gail Lasser
Recruiter, Human Resources
Access Health Care Physicians, LLC
Phone: 352-277-5304
Fax: 352-688-6189
Students MUST contact their USA Faculty to request
this site.
Access Community Health Network
Chicago, IL (see Exhibit A for complete
MSN, DNP
USA/Faculty: Please see Exhibit A for all Facility
Sites.
Student: Must obtain comprehensive health
insurance. Provide at facility's request
documentation of required immunizations, to include
flu vaccination and OSHA compliance and general
HIPAA training.
Agency contact: Monica Climer, Coordinator
Graduate Clinical Student-mclimer@adena.org- 740779-8821
lists of affiliates covered by agreement)
(Renewal request sent, set to expire
7/14/2016)
Adena Health System
Chillicothe, Ohio
MSN, DNP
1
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
USA/Faculty: Complete Attestation (Exhibit A).
Inform facility of curriculum and sequence and of all
courses and clinical experiences for each student.
Notify facility of proposed schedule of student
assignments to facility, including dates, number and
names of students, their level of academic
preparation.
Student: Complete Exhibit B. Obtain health
insurance coverage for the period of the clinical
experience.
Adventist Health System Georgia,
Inc. d/b/a Gordon Hospital
AHS Oklahoma Health System, LLP
(Utica Park Clinic)
Tulsa, Oklahoma
Akron General Medical Center
Akron, Ohio
Alabama Department of Public
Health, (Alabama inclusive)
Alabama Department of
Rehabilitation Services
Mobile, Alabama
Alaska Regional Hospital
RN-BSN, MSN, DNP
MSN, DNP
See Exhibit A for covered facilities. See Exhibit C for
Background Requirements.
Student must complete and sign Exhibit D.
Graduate
GRADUATE STUDENTS.
USA must notify agency one month prior to
beginning of clinicals for each student. USA Faculty
must provide orientation session to preceptor to
include: goals, objectives of program, faculty’s
contact information, and overview of expectations.
Students must have current RN license in the state
of practice. Student must participate in orientation
procedures as required by agency.
BSN, RN-BSN, MSN,
DNP
BSN, RN-BSN, MSN,
DNP
MSN, DNP
USA/Faculty: Verify and complete Attestation-Exhibit
C.
(renewal request sent, set to expire
8/31/2016)
Student: Complete and sign Exhibits A and B. Must
have proof of influenza vaccination during the Flu
season (October 1-March 31) or a signed Declination
Form. This background check must include
requirements of the State of Alaska Background
Check Unit, including fingerprints per mandate of
7AAC10.900-10.990. Please note: Regarding drug
and alcohol testing:
(i) To ensure the accuracy and fairness of the
testing program, all collection and testing will be
conducted pursuant to guidelines established by the
Medical Review Officers of the testing Hospital and,
if applicable, in accordance with Substance Abuse
and Mental Health Services Administration
(SAMHSA) guidelines; a confirmatory test; the
opportunity for a split sample; review by an MRO,
including the opportunity for employees or students
who test positive to provide a legitimate medical
explanation, such as a physician's prescription, for
the positive result; and a documented chain of
custody.
Agency Education Contact: Zachary Owen
zlowen@anthc.org.
USA/Faculty: Provide to Facility a listing of students
who will be participating in clinicals. Also provide to
Anchorage, Alaska
Alaska Tribal Health
Consortium/Alaska Native Medical
Center
Students may be required to undergo a health
examination.
Nursing
2
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Facility any change in student’s status. Provide
opportunity to receive Hepatitis B vaccine to clinical
students.
Student: Must provide drug test results to Facility's
Human Resources Department during the onboarding process. Must maintain personal medical
insurance coverage while at Facility. Must have
training in universal precautions and transmission of
blood-borne pathogens.
Anchorage, Alaska
Albany Primary Health Care, Inc.
(renewal request sent, set to expire
6/14/2016)
Albany, Georgia
Alegent Health
Omaha, Nebraska
Allegan Healthcare Group
BSN, RN-BSN, MSN,
DNP
NP
Faculty and Students please read Exhibit
A
(renewal request sent, set to expire
5/31/2016)
Allegan, Michigan
AllWell Behavioral, LLC
Warner Robins, Georgia
AltaPointe Health Systems, Inc.
(formerly Mobile Mental Health and Baldwin
Mental Health)
BSN, RN-BSN, MSN,
DNP
AltaPointe Health Systems, Inc. (Baldwin County
Mental Health site)
Renee Presley- rpresley@altapointe.org or (251)
378-6528 or (251) 378-6528
Mobile, Alabama
AltaPointe Health Systems, Inc. (Mobile site)
Kelly Hughes - ceo@altapointe.org or (251) 4734423
Students and Faculty: Request to see Addendum
under Agreement Attachments (immunization
requirements). See Orientation Information in
Agency Attachments.
Altru Health Systems
Grand Forks, North Dakota
American Family Care, Inc.
Birmingham, Alabama
American Health Network of Ohio,
PC
Indianapolis, Indiana
Andalusia Regional Hospital
Andalusia, Alabama
Anderson Regional Medical Center
and Anderson Regional Medical
Center-South Campus
Meridian, Mississippi
AnMed Health
Anderson, South Carolina
Anniston Pediatrics, Inc.
Anniston, Alabama
Please note the contact person for clinicals are as
follows:
BSN, RN-BSN, MSN,
DNP
USA/Faculty: Verify annual negative Tuberculin skin
test or if positive, a negative chest X-ray; Hepatitis B
immunization status; and physical exam prior to
clinicals.
BSN, RN-BSN, MSN,
DNP
3
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Apogee Medical Management, Inc.
Phoenix, Arizona
Appalachian Regional Healthcare
Boone, North Carolina
Advanced Practice
Nursing
Students: Must maintain health insurance during
clinicals. Must have education in OSHA/Blood Borne
Pathogens and HIPAA regulations prior to clinicals.
USA/Faculty: Will send information to
the facility prior to initiation of clinicals to
include dates of assignment, number of
students, name and pertinent information
about students, objectives for clinical,
curriculum outline and types of previous
healthcare/clinical experience. Provide facility
with an exposure control plan and guidelines
for its students in accordance with OSHA
Standards for Bloodborne Pathogens and TB
or other applicable guidelines upon request.
Student: Must obtain adequate health
insurance.
USA/Faculty: Must complete Exhibit A, return to
contract office for signature, then return to Education
Coordinator at ARH facility. Contact the Education
Coordinator at the ARH facility student will be
seeking placement.
Appalachian Regional Healthcare,
Inc.
Hazard, Kentucky
Student: Obtain health insurance coverage.
Faculty must provide facility official with students’
names, dates, and hours of assignment and level of
care by students.
Faculty must submit schedule and names of
students three weeks prior to clinical rotation.
Arkansas Children’s Hospital
Little Rock, Arkansas
Armed Forces Retirement HomeGulfport
Gulfport, Mississippi
Asante Physician Partners
Medford, Oregon
Student: That all students will have met health and
immunization requirements as outlined in the
University’s policies for each Program and will
provide proof of current immunization for tetanus,
diphtheria, hepatitis B, measles, mumps, rubella,
varicella, Influenza, and 2-step skin test for
tuberculosis (one within the past 12 months and the
second within 4 weeks of hire) as required by
Agency’s policies (see Exhibit “A”. Student who
experiences an HIV exposure incident should seek
emergency counseling and treatment. Abide by
existing policies, rules, regulations of Agency and
the University, Code of Conduct, Code of Ethics of
any professional society or association for which the
Student is in training, and all HIPAA laws and
regulations. Student shall maintain Auto Insurance at
their own expense. Responsible for contacting
Agency to schedule orientation at the Agency prior to
start of the clinical experience. [Complete Agency
training modules related to HIPAA and CMS
accreditation standards].
Student must retain Caregiver’s Background Check
under Wisconsin law through the Department of
Health Services. The results must be given to USA
for their records.
Aspirus, Inc.
Wausau, Wisconsin
Athens Regional Health Services,
Inc.
Nursing
4
USA/Faculty: Provide student and program
information to facility 15 days prior to clinicals -
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
facility student placement contact: Nicki Turner 706475-3594 nturner@armc.org.
Athens, Georgia
Student: must complete and sign Exhibit B and C.
Background check must be completed within six (6)
months prior to clinicals. Upon request from facility,
Student may be required to obtain a background
check through PreCheck, Inc. Results must be made
available to facility.
Faculty should contact Tajuane Dockery 803-8654793 tajuane.dockery@providencehospitals.com to
schedule students participating in clinicals.
Augustine Health Group, LLC
Columbia, South Carolina
Graduate
Aurora Medical Group, Inc.
Milwaukee, Wisconsin
Avera Health (to include Avera
BSN, RN-BSN, MSN,
DNP
McKennan, Avera St. Luke’s, Avera
Queen of Peace, Avera Sacred Heart
Hospita, Avera St. Mary’s, Avera
Marshall, Avera St. Benedict Health
Center, Aveara St. Anthony’s, Avera
Holy Family, Avera@Home, and Avera
Health Plans, Inc.)
Sioux Falls, South Dakota (main ofc.)
Avera St. Luke’s
Aberdeen, South Dakota
Azalea Health (Rural Health Care,
Inc.)
Palatka, Florida
Students complete Exhibit B.
To include all Aurora Health Care, Inc. facilities.
Faculty, please see Exhibit A-program
memorandum.
USA/Faculty: Upon request submit to agency the
dates, time, number and academic level of
students to be assigned to each unit within
agency. Name, license number and credentials of
faculty member providing the practicum
instruction. Prior notice of any proposed
changes to any assigned student's schedule.
Complete the Faculty Verification of Student
Orientation form.
Student: See Agency immunization guidelines.
Complete HIPPA training prior to clinicals.
BSN, RN-BSN, MSN,
DNP
BSN, RN-BSN, MSN,
DNP
B
Baker County Health Department
Macclenny, Florida
Baldwin County Public Schools
Fairhope, Alabama
Banner Health
Phoenix, Arizona *Now Banner
Health agreement also covers:
University Medical Center Corp. and
University Physicians
Tucson, Arizona*
BSN, RN-BSN, MSN,
DNP
Faculty must notify school prior to clinical experience
Faculty and Students please see the
facility’s Policies and Procedures for
the Influenza Vaccination of Healthcare
Personnel. Please see ALL exhibits.
Students must complete the Influenza
Attachments.
Students are responsible for their own health
insurance.
Students are required to complete a BH Orientation
which may include on-line lessons.
5
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Faculty and Students please refer to Exhibit AHealth Standards (available from the contract office)
Students must comply with OSHA guidelines and
training. If student’s program requirements include
access and experience with patients in isolated
rooms, due to airborne infectious disease, student
must have obtained a respiratory mask-fit testing as
required by OSHA.
Students may be asked to submit to a “for cause”
drug screening by BH. Students must agree in
writing that BH may at any time require a “for cause”
drug screen, execute consent for release of results
of such screen information to BH. Student may be
precluded from participating in a Rotation at BH if
“for cause” drug screen is declined or student does
not execute consent of release.
BH shall conduct a background investigation on (onsite) Faculty and students participating in the
Program at BH. USA shall provide BH with any
information necessary to conduct such background
checks.
Students are not permitted access to the physician
parking area or physician lounge.
Faculty shall provide BH a current copy of the
applicable Program syllabus for all students in each
Rotation, as well as the approved Statement of
Objectives for the clinical experience desired of its
students. Faculty shall supply student names no less
than fourteen (14) days prior to Rotation.
Faculty must notify BH of any student placed on the
Sanctions list by the Department of Health and
Human Services.
Baptist Health Care Corporation
Pensacola, Florida
BSN, MSN, DNP
Includes: Baptist Hospital, Pensacola, FL
Gulf Breeze Hospital, Gulf Breeze,
FL
Atmore Community Hospital,
Atmore, AL
Baptist Medical Group, Pace, FL
Attestation Form must be completed and
signed by USA Faculty and emailed to
Barbara Hamiltonbarbara.hamilton@bhcpns.org
USA/Faculty: Provide any requested student
information (licensure, immunization record, TB skin
test, background check results) to Facility.
Student: Complete the Statement of Understanding
and Confidentiality Agreement.
Baptist Health Madisonville, Inc.
Madisonville, Kentucky
Baptist Health Medical Center-North
Little Rock
Little Rock, Arkansas
Baptist Health System (coversPrinceton, Shelby, Walker and Citizen’s)
Students please request Exhibit A and B
prior to starting clinicals and bring with
you to the Baptist Health Care
Orientation. Must be completed before
clinicals.
Nursing
BSN, RN-BSN, MSN,
DNP
Birmingham, Alabama
Agency Education Contact: Vicki Hill-205-783-7067vicki.hill@bhsala.com.
USA/Faculty: Provide written statement of objectives
for each clinical rotation as requested.
Students: Must complete orientation program as
designated by Agency prior to clinical experience.
Must avoid contact with respiratory isolation unless
fit tested with the N95 3M mask. Must have training
6
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
in HIPAA requirements and OSHA regulations.
Bay Medical Center –Sacred Heart
Health System
Panama City, Florida
Baptist Health System-Florida
Jacksonville, Florida
Nursing
BSN, RN-BSN, MSN,
DNP
USA Faculty and Students please see Exhibit A for
facilities covered by agreement.
Contact: Kristy Johnson 904-202-8390.
USA/Faculty: Provide student names, days and
hours they will be assigned and services which their
assignment is desired in a timely manner. Provide
statement of health status for each student, to
include proof of immunity to Rubella, Rubeola and
chicken pox or provide documentation of appropriate
vaccinations, and completed OSHA form
documenting negative TB skin test within 90 days of
participation in the Program. Facility may require
liability insurance indicate students name, if
requested please contact the USA Clinical Affairs
Department.
Student: Complete Exhibit B-Participation
Agreement.
*Student must complete Exhibit A & B before
starting clinicals. (See Faculty for information)
*Students are required to have flu and HINI vaccines
by December 15, 2009 and the Proof of Vaccination
form must be completed prior to clinicals. (See
faculty member regarding form).
Student must sign Statement of Understanding and
Confidentiality Agreement.
Baptist Health System
San Antonio, Texas
Baptist Healthcare System, Inc.,
d/b/a Baptist Health Lexington
Lexington, Kentucky
Baptist Health System, Inc. d/b/a
Baptist Health Paducah
Paducah, Kentucky
USA/Faculty: Complete Exhibit C-Attestation
Students: Complete Exhibits A & B.
BSN, MSN, DNP
USA Faculty must provide student info to hospital at
least 30days prior to beginning clinical .Faculty who
make on-site visits must be licensed in Kentucky
with current TB skin tests and immunizations.
Students must complete and sign Exhibit B and
obtain signature of preceptor (physician) Exhibit A.
USA Faculty must have a current, active,
unencumbered APRN license in state of practice.
Faculty must complete Schedule A. Student must
complete the Student Agreement and
Acknowledgement form. Faculty must have
Baptist Hospital of Miami (to include:
Doctors Hospital, Inc., Homestead
Hospital, Inc., South Miami Hospital,
Inc., Mariners Hospital, Inc., West
Kendall Baptist Hospital, Inc., and
Baptist Outpatient Services, Inc.,)
active Florida license and CPR
Certification. Please ask for Section 9
School Certification forms.
Baptist Medical Group
MS and TN
MSN, DNP
USA/Faculty: Upon request, provide written copies
of the general curriculum and clinical experience
objectives to a Baptist designee. Complete Exhibit A
with USA's preceptor guidelines.
Student: Must fully complete and return Attachment
One-Preceptor Agreement. Will be required to sign
an affidavit regarding the student's prior criminal
history as required.
Baptist Medical Center South
BSN, RN-BSN, MSN,
DNP
See attachment A-Competency Validation Policy
Clinical Instructors and Students.
Students must complete required training before
beginning training. Student may be required to sign
(includes Baptist Medical Center East
and Prattville Baptist Hospital)
7
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
an individual agreement with agency.
Montgomery, Alabama
Baptist Memorial Hospital – Golden
Triangle
Columbus, Mississippi
Baptist Memorial Hospital-Union
City
Union City, Tennessee
Programs: RN-BSN, MSN, PM Cert, DNP
USA/Faculty: Provide written copies of the general
curriculum and clinical experience objectives to a
Baptist designee if requested.
Students: Must have satisfactory physical
examination, annual TB test, Hepatitis B vaccine
series or signed waiver; students born on or after
1957 must have two MMR vaccines given after one
year of age or serologic evidence of immunity to
Rubella and Rubeola; Must have annual influenza
vaccine. Must have background check no earlier
than one year prior to the clinical placement.
Student must complete and sign Exhibit A. USA
Faculty must prepare a written evaluation of
students’ strengths, weaknesses, and general
performance in meeting Program objectives and
competencies at end of clinical as well as submit
the final letter grade assigned for the experience
to the students. USA Faculty must have a
current, active, unencumbered APRN license in
state of practice.
Baptist Physicians Lexington, Inc.,
d/b/a Baptist Internal Medicine
Group (Baptist Medical Group)
Lexington, Kentucky
NP
Barnes-Jewish Hospital
St. Louis, Missouri
NP, DNP
Barnes-Jewish Hospital
St. Louis, Missouri
CNS
Baton Rouge General Medical
BSN, RN-BSN, MSN,
NP and DNP Students
***Please see agency specific LON under the
agency attachments in Sakai***
USA/Faculty: Provide facility with names, health
status reports, immunizations required by facility
prior to beginning of clinicals. Verify that student has
completed and passed the requirements noted in the
BJC guidelines (Exhibit 2). Meet with facility
personnel prior to and following clinicals. Must
provide proof of student's general liability
insurance.
Students: Must sign Statement of Confidentiality
(Exhibit 1). Must obtain and maintain health
insurance.
CNS Students
***Please see agency specific LON under the
agency attachments in Sakai***
USA/Faculty: Provide facility with names, health
status reports, immunizations required by facility
prior to beginning of clinicals. Verify that student has
completed and passed the requirements noted in the
BJC guidelines (Exhibit 2). Meet with facility
personnel prior to and following clinicals. Must
provide proof of student's general liability
insurance.
Students: Must sign Statement of Confidentiality
(Exhibit 1). Must obtain and maintain health
insurance. Must obtain and maintain general
liability insurance with amounts of $1 million per
occurrence, $3 million annual aggregate, on an
occurrence basis.
8
Physician Assistant, Physical Therapy, Occupational
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Center (and its affiliates)
Baton Rouge, Louisiana
DNP
Baxter Regional Medical Center
Mountain Home, Arkansas
BSN, RN-BSN, MSN,
DNP
Therapy and Nursing Students contract. All students
must be approved for the rotation through the
Education Dept. at BRGMC. Faculty must contact
Ms. Sellers (contact info under agency attachments)
to coordinate any scheduled clinicals. Faculty,
please see the agency attachments that must be
completed. Faculty and Students please see the
BRGMC Affiliate List.
USA Faculty please see Exhibit D: ONBOARDING
Nursing Clinical Programs at Facility.
USA/Faculty: Must provide Instructor name and
contact information to Aleta Newberry
anewberry@baxterregional.org..
Student: Must provide evidence they have met all
applicable requirements of current AHA CPR
certification, TB Mantoux test, MMR immunity, and
compliance with OSHA requirements for prevention
of transmission of blood borne pathogens and TB.
Must obtain and maintain comprehensive healthcare
insurance during clinicals. Must attend Facility's
orientation to include HIPAA training, Infection
Control, Safety Requirements, and No Smoking
Policy.
Florida Department of Health- Bay
County
Panama City, Florida
BayCare Health System, Inc. (to
include: Morton Plant Hospital Association, Inc.
d/b/a Morton Plant Hospital and Morton Plant
North Bay Hospital; Trustees of Mease Hospital,
Inc. d/b/a Mease Countryside Hospital and Mease
Dunedin Hospital; St. Anthony’s Hospital, Inc.; St.
Joseph’s Hospital, Inc. d/b/a St. Joseph’s
Children’s Hospital, St. Joseph’s Women’s
Hospital, and St. Joseph’s Hospital - North; South
Florida Baptist Hospital, Inc.; BayCare Alliant
Hospital, Inc.; BayCare Behavioral Health Inc.
d/b/a The Harbor Behavioral Health Care Institute,
Inc.; Behavioral Health Management Services,
Inc. d/b/a BayCare Life Management, Inc.;
BayCare Home Care, Inc.; SC Physicians, LLC;
St. Anthony’s Specialists, LLC; St. Anthony’s
Primary Care, LLC; Morton Plant Mease Primary
Care, Inc.; HealthPoint Medical Group, Inc.; and
Winter Haven Hospital, Inc.)
Nursing
BSN, RN-BSN, MSN,
DNP
Faculty and Students please see Attachment B
(Employee Health Requirements for Students and
Faculty & Attachment C (Team Resources
Contractor Requirements for Students and Faculty).
Clearwater, Florida
Bayfront Health St. Petersburg
St. Petersburg, Florida
Bayshore Medical Center
APRN students must complete the “Physician
Sponsored Student Application”
MSN, DNP
9
USA/Faculty: Educate students about clinical safety
and OSHA blood borne pathogens standards and
tuberculosis transmission prevention prior to
clinicals.
Student: Please see Addendum 1-5. Must have a
negative TB skin test within the past year or if a
positive TB skin test a chest x-ray within the past 3
years. Completed series of Hepatitis-B vaccine, or
informed refusal of the vaccine. Must obtain health
insurance coverage.
USA/Faculty: Provide letter of attestation for each
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Pasadena, Texas
Bellin Memorial Hospital, Inc.
Green Bay, Wisconsin
Bellin Psychiatric Center, Inc.
Green Bay, Wisconsin
Beth Israel Deaconess HospitalPlymouth
Plymouth, MA
Beverly Healthcare
Foley, Alabama
Billings Clinic
Billings, Montana
MSN, DNP
Nursing
Submit list of student(s) and course objectives,
course descriptions to Agency.
Students-Annual Manatoux tuberculin test. Provide
annual documentation of influenza immunization or
declination form, where student will wear a surgical
mask when on-site and while the influenza virus is
active in the community. Must have health insurance
coverage.
BSN, RN-BSN, MSN,
DNP
USA/Faculty: Notify agency of the planned
schedule for student assignment, including
student name, level of academic preparation,
length and dates of clinicals. Provide program
syllabus and University student handbook to
facility.
Students: Background check completed within
the most recent one year period in any state
where the student resided within the last ten
years. Drug screen completed with the most
recent one year period. Provide evidence of
HBV vaccination or evidence of declination.
Students must sign a Statement of Responsibility,
Exhibit A, and a Statement of Confidentiality, Exhibit
B. Following is required prior to clinicals by
Mississippi Department of Health: Background check
state of MS. (addl Fee), MMR, PPD-must be within 1
year of expected date of completion of clinical
rotation. Health and must have a MS background
check prior to background screening attestation form
(Exhibit C) being completed by University Official.
Faculty must provide schedule for the length of time
the students will be in the facility 14 days prior to
rotation.
Biloxi Regional Medical Center
Biloxi, Mississippi
BJC Hospice
St. Louis, Missouri
student.
Student: Complete Exhibits A & B.
Students must complete agency’s application,
Wisconsin Background Information Disclosure form,
return agency’s HIPAA confidentiality agreement,
self-study orientation packet and test must be
completed prior to start of rotation. Student must
have a Wisconsin Caregiver Background check
completed. Contact is Beth Markon: (920) 433-7858
DNP, NP
USA/Faculty: Provide Facility with the names,
health status reports, including immunizations
required and any other pertinent information.
Obtain Facility's approval of students and
period of clinicals. Must provide evidence of
completion and passed the requirements
noted in Exhibit 2.
Student: Must complete and sign Exhibit 1Confidentiality Acknowledgement. Must
provide evidence of health insurance to
Facility.
10
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Bladen County Health Department
(renewal request sent, set to expire
8/19/2016)
Elizabethtown, North Carolina
Blanchfield Army Community
Hospital
Fort Campbell, Kentucky
Blue Ridge Healthcare
MSN, DNP
(Renewal request sent, set to expire
7/31/2016)
Morganton, North Carolina
Boise VAMC
Boise, Idaho
Boone Hospital Center
Columbia, Missouri
Boulder Medical Center, P.C.
Boulder, Colorado
Bronson Healthcare Group
Kalamazoo, Michigan
Brookwood Health Services, Inc.
Birmingham, Alabama
Brookwood Physician Practices,
LLC (covers Cahaba Heights,
Homewood, Hoover, Narrows, Oak
Mountain, Vestavia,
Inverness, Greystone Internal
Medicine)
Birmingham, Alabama
Brynn Marr Behavioral Healthcare
System Jacksonville, North Carolina
AGACNP
NP Students
USA/Faculty: Provide Facility with names, health
status reports prior to student beginning clinicals.
Agency contact: Donna Duffy-dduffy@bjc.org. See
Exhibit 2 for reference to background check and
drug screening.
Student: Must provide evidence of health insurance
to facility. Complete Exhibit 1.
Student must complete Exhibits A&B.
BSN, RN-BSN, MSN,
DNP
Students must meet requirements as outlined in
Addendum A prior to the beginning of clinicals.
Students please note obligations also outlined in
Addendum A.
BSN students: Request Attachments A-C prior to
clinical. They are Statement of Responsibility,
Confidentially Statement, and Background
Screening Attestation.
BSN, MSN, DNP
Nursing
NP students: Complete Exhibits A-C prior to
clinical. Students must obtain and maintain
commercial general liability insurance with an
insurer approved by Brookwood. Such coverage
shall have limits of at least $1,000,000 per
occurrence and shall not be cancelable except
upon 30 days' prior written notice to us and to
Brookwood. Students must provide a copy of
their certificate of insurance to us and to
Brookwood as evidence of said coverage.
USA/Faculty: Complete Exhibit D-Attestation.
Student: Complete Exhibits B & C.
Students must be trained consistent with applicable
requirements by facility to the facility’s policies and
procedures.
11
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
C
Cabell Huntington Hospital
Huntington, West Virginia
Cape Fear Valley Health System
(Bladen County Healthcare)
Elizabethtown, North Carolina
Capital Medical Center
Olympia, Washington
Cardiovascular Institute of the South
Houma, Louisiana
Carilion Clinic
Roanoke, Virginia
Advanced Emergency
NP
USA/Faculty: Will submit to Facility three weeks prior
to the beginning of each clinical, a schedule
indicating the number and names of students who
will be participating and the name of the faculty who
will be supervising the students during their clinicals.
Advanced Emergency NP's Only.
USA/Faculty: Provide an evaluation from to be
completed by Health System. Provide objectives for
the clinical period, and outline of academic curricula.
Notify Health System in advance concerning number
of students to be assigned to Health System.
Complete and sign Appendix 1.
RN-BSN, MSN, DNP
Students: Must comply with the policies and
procedures provided by Health System.
Student must complete exhibits A & B.
USA/Faculty: Each Student and Faculty member
must meet with the criteria set forth in Addendum B
within 60 days prior to clinicals. Contact the facility in
writing at least 3 weeks in advance of a new
placement. Must forward student names at least two
weeks prior to their arrival.
Student: Student must meet with the requirements
set forth in Addendum A.
USA/Faculty: Provide required documentation
(student name, dates and times of clinical, goals and
objectives of each clinical) to Facility (Edie Suhay
phone: 520-873-3719 Esuhay@carondelet.org) at
least 2 weeks prior to clinical. Ensure that student
has been provided with HIPAA compliance
education prior to clinicals (Facility may request
evidence of such training).
Carondelet Health Network
Tuscon, Arizona
Students: Must complete Student Agreement and
application information packet. Must be trained in
compliance with OSHA Blood-Borne Pathogen
Regulations and infection control procedures prior to
clinicals
CarolinaEast Health System (to
include CarolinaEast Physicians)
New Bern, North Carolina
CarolinaEast Medical Center and
Emergency Medicine Physicians of
Craven County (3-way agreement)
New Bern, North Carolina
Carl R. Darnall Army Medical Center
Fort Hood, Texas
NP
Nurse Practitioner Students
Student: Must complete Exhibit B. Provide all
requested documentation of immunizations to facility
prior to clinicals.
Preceptor must be employed by Emergency
Medicine Physicians.
Nurse Practitioner Students
Student: Must complete Exhibit B. Provide all
requested documentation of immunizations to facility
prior to clinicals.
NP
Nursing
12
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Carson Tahoe Health
Carson City, Nevada
Facility will not be held liable or financially
responsible for any injuries sustained by or for the
care provided to a student or USA instructor during
the clinical experience.
Agency Education Contact:
NP
CJ Ojanpera
cj.ojanpera@carsontahoe.org
Catawba Valley Medical Center
Hickory, North Carolina
RN-BSN, MSN, DNP
USA/Faculty: Student Placement Request Form
must be requested from CTHS and completed and
submitted by USA prior to and for every clinical
placement-Student Rotation Form (must be verified
by Mary Meyer and signed by the Associate Dean for
Clinical Affairs. USA must submit completed
Preceptor Form, HBV Vaccination Form, and
Seasonal Flu Vaccination Form at least 2 weeks
prior to clinical.
Student: Student must complete and sign the HBV
and Flu Vaccination forms.
USA Faculty: Upon request please provide the
following;

Objectives of the Experience

Course Titles

Number of Students

Dates, days and times of Experiences

School’s Faculty names/qualifications

Departments to be utilized
Student: Must have appropriate health insurance.
Must have a North Carolina criminal background
check prior to placement, must include a minimum
of 7 years.
Cathedral Place Apartments
Mobile, Alabama
CDH-Delnor Health System (to
BSN, MSN, DNP
Nursing
include: Central DuPage Hospital, CDH
Cancer Center, Bartlett Convenient
Care, Bloomingdale Convenient Care,
Glen Ellyn Convenient Care, Naperville
Convenient Care, St. Charles
Convenient Care, and Wheaton
Convenient Care)
Winfield, Illinois
Centegra Health System (covers All
inpatient and outpatient locations of
Centegra Health System hospitals,
including Centegra Physician Care
locations).
Woodstock, Illinois
Centennial Heart, LLC
Nashville, Tennessee
Centra Health
Lynchburg, Virginia
RN-BSN, MSN, DNP
USA must provide evidence that student has met
all requirements of CPR certification, Hepatitis B
vaccination, and OSHA compliance for
prevention of blood borne pathogens and TB.
Student must comply with Program Specific
Requirements: Background Check and Drug
Screen as outlined in Exhibit C.
PLEASE SEE EXHIBIT C-Agency Requirements.
Students must obtain prior written approval of the
Site prior before publishing any material relating to
clinical experience.
USA/Faculty: Must complete Exhibit C-Attestation
and submit to agency.
MSN, DNP
13
Student: Must complete Exhibits A&B and submit to
agency.
Students utilizing this agreement must submit a
copy of their own personal professional liability
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
insurance to the Clinical Affairs department,
through their USA Faculty, at the USA CON and
the agency before beginning clinicals. This
insurance must be obtained in the amounts
indicated on the attachment. Student also must
provide copy of health insurance coverage to
agency.
USA/Faculty: Submit a schedule of students name
to the Unit Manager of the appropriate area where
student(s) will be assigned seven days prior to
clinicals. Please provide, course description, course
objectives, course schedule, number of students
(agency contact: Roberta Vick, Managing Director,
Professional Development.
roberta.vick@centrahealth.com
Central Alabama Veterans
Healthcare System
Montgomery and Tuskegee
Alabama
Central Arkansas Veterans
Healthcare System
Little Rock, Arkansas
Central Carolina -CIM, LLC, Central
Carolina-IMA, LLC Tenet Central
Carolina Physicians, Inc., Central
Carolina Physicians-Sandhills, LLC,
North Carolina Community Family
Medicine, LLC and any other
physician practice acquired by Tenet
Healthcare Corporation
Sanford, North Carolina
AMISUB of North Carolina, d/b/a
BSN and MSN
BSN, RN-BSN, RNMSN
BSN, RN-BSN, RN-MSN, MSN, and DNP
NP
Nurse Practitioner Students Only
USA/Faculty: Complete the Exhibit A-Attestation
Statement and return to Jessica Ouellet 919-7777925-jessica.ouellet@tenethealth.com. Upon
request participate in the Clinic's Quality Assurance
and related programs.
Students: Must complete Exhibit B-Confidentiality
Agreement and Statement of Responsibility. Must be
educated with OSHA Compliance to include
provisions of the hepatitis B vaccination or
documentation of declination in accordance with the
Regulations. Must view a videotape (provided by
facility) regarding Clinic's patient information privacy
policies and practices and achieve a passing score.
Must read the facility's Standards of Conduct
available at http://www.tenethealth.com/about/ethicscompliance.
USA/Faculty: Student must be supervised by on-site
licensed physician. Provide evidence of requested
Student health and immunizations information. Must
attest to Hospital that a background check has been
completed for each Student, by completing Exhibit B.
Please review Tenet’s Standards of Conducthttps://www.tenethealth.com/about/ethicscompliance. Agency contact: Jessica Oullet919.777.7925-Jessica.Ouellet@tenethealth.com.
NP
Central Carolina Hospital
(part of the Tenet Healthcare
Corporation)
Sanford, North Carolina
Central Florida Healthcare, Inc.
Winter Haven, Florida
Central Iowa Hospital, Corp. d/b/a
UnityPoint Health - Des Moines
BSN, RN-BSN, MSN,
DNP
Nursing
14
Student: Must complete Exhibit A-Confidentiality
Statement. Student must comply with the final
regulations issued by OSHA governing employee
exposure to bloodborne pathogens in the workplace.
Agency may put limit on amount of students per
semester.
USA Faculty: Must give each student participating in
clinicals at facility a Student Orientation Manual.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Instructors will need a valid license in the state of
Iowa to practice nursing or any other required
license application to the position. Clinical
Professional Development # 515-241-5576.
Student: Will have completed an Iowa Department of
Public Health approved Child & Dependent Adult
Abuse training program.
Des Moines, Iowa
Central Missouri Physicians for
Women (Michael L. Burks, M.D.,
P.C.)
Columbia, Missouri
Central Plaza Towers
Mobile, Alabama
Central Utah Clinic
Provo, Utah
Centura Health (to include: Avista
Adventist Hospital, Porter Adventist Hospital,
Littleton Adventist Hospital, Parker Adventist
Hospital, Penrose Hospital, Penrose
Community Hospital, St. Francis Hospital,
St. Anthony Summit MC, St. Mary-Corwin
MC, St. Thomas More Hospital, Porter
Hospice, Mercy Regional MC, Centura
Home Care and Hospice, Centura Senior
Life Center)
BSN, RN-BSN, RNMSN
Englewood, Colorado
Charlotte Mecklenburg Hospital
Authority d/b/a Carolinas
HealthCare System (Covers ALL CHS
BSN, RN-BSN, RNMSN
facilities)
Charlotte, North Carolina
USA/Faculty: All clinicals need to have prior approval
by agency. Agency contact-Becki Holt
bholt@centralutahclinic.com
Student: Must obtain an active Workers'
Compensation Policy OR has obtained a Workers'
Compensation Coverage Waiver from the Utah
Labor Commission and a copy has been provided to
the agency prior to clinicals.
Information:
http://centralutahclinic.com/content/medical-schoolrotations-0
Agency utilizes MyClinical Exchange. Cost to student
is $36.50 per year.
USA/Faculty: Shall provide applicable curricula to
Facility -Angela Shopp - angelashopp@centura.org.
Shall provide Facility with records of student's
physical exam, immunization status, and other
medical tests; including but not limited to mumps
titer, measles titer, rubella titer, TB test, hepatitis B,
Polio, varicella, and tetanus. Provide documentation
of necessary training in OSHA regulations, HIPAA
requirements, and BLS certification. Must submit
letter to Facility, verifying that each student's criminal
background check is acceptable to JCAHO standard
and Facility's standards.
USA/Faculty: Please see training modules in the
Clinical Affairs project site or request from the
Clinical Affairs Department. Provide the following
information to agency prior to clinicals; proposed
dates of clinical, number of students, names and
pertinent identification information, objectives for
clinical experience, suggested curriculum outlines,
students’ prior clinical experiences.
Student: Student who are former employees of CHS
and are not eligible for rehire shall not be accepted
for assignment. Provide facility with immunization
history, criminal background check; complete a
social security number search to determine if a social
security record is present in another state. Must
complete a screening through the North Carolina
Sex Offender and Public Protection Registry.
Complete a North Carolina State Bureau of
Investigation screening (SBI Screen) as required by
North Carolina law. Complete a Federal Criminal
15
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
History screening (FCH Screen), to include a
fingerprint check in addition to any fingerprint check
required by the SBI Screen for any student who has
not been a resident of North Carolina for a period of
at least five years preceding March 13, 2014.
Complete a drug test using a urine specimen.
Students who have the potential for exposure to
receive the hepatitis B vaccination or declination
statement.
Chattanooga-Hamilton County
Hospital Authority d/b/a Erlanger
Health System
Chattanooga, Tennessee
CHI St. Luke’s Sugar Land Hospital
Sugarland, Texas
BSN, RN-BSN,
MSN, DNP
FACULTY NOTIFY USA CLINICAL AFFAIRS
PRIOR TO PLACEMENT OF STUDENT
USA/Faculty: Agency contact: Earika Harris281.637.7140-eharris@stlukeshealth.org.
CHI St. Vincent Hot Springs
Hot Springs, Arkansas
RN-BSN, MSN, DNP
Student: Must complete Exhibits A&B. Must have
current physical examination. Must have completed
OSHA training (to include, universal precautions and
infection control, body mechanics, fire safety and
disaster safety, HIPAA.
USA Faculty and Students:
CHI Standards of Conduct are set forth in Our
Values & Ethics at Work Reference Guide
(“Reference Guide”), which is available at the
following website:
http://www.catholichealthinit.org/body.cfm?id=37940
As of the date of the Agreement, the Directives are
available at the following website:
http://www.usccb.org/about/doctrine/ethical-andreligious- directives/
Student: Review and complete attachments A and B.
Children’s Healthcare of Atlanta
(covers Egleston and Scottish Rite)
Atlanta, Georgia
Children’s Hospital
New Orleans, Louisiana
BSN, RN-BSN, MSN,
DNP
Children’s Hospital
Washington, D.C.
Children’s Hospital & Clinics of
Minnesota
Minneapolis, MN
(Minnesota sites should only be
utilized by approved USA students)
Pediatrics
RN, RN-BSN,
MSN, NP
Students must complete Exhibits A, B-1, and C prior
to clinical.
USA/Faculty: Update facility on program of clinical
experience. Send name and bio of each student to
facility at least four weeks before the beginning of
clinical experience.
Student: Will be given state required health tests.
Must provide own health insurance. See Holiday
schedule that must be followed.
USA/Faculty: Please reference Exhibit A-Operating
for Clinical Education Agreements. Provide Facility
with list of students participating in the clinical
experience, along with the units’ locations and dates
of each participation.
Student: Must sign a Confidentiality Statement
provided by Facility. Must provide Facility with results
of health examination with updated immunizations
16
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
and to include a mantoux test or chest x-ray and
verification of immunity for rubeola and rubella.
Children’s Hospital Medical Center
of Akron
Akron, Ohio
Pediatrics
For any student who is interested in going to Akron
Children’s Hospital for their preceptor program, the
first step needed is to fill out a redcaps survey at,
http://www.akrondb.org/surveys/?s=7ZYnLq
USA/Faculty: Provide appropriate evidence that
student participating in clinicals has satisfied the
facility's infection control and wellness policies, to
include immunizations, yearly flu vaccine, and urine
10-panel drug screen. Provide attestation or
evidence of compliance at least 2 weeks prior to
clinicals.
Student: Student will pay a $20 fee for their badge if
not returned. Must submit fingerprints to the Bureau
of Criminal Identification and/or Federal Bureau of
Investigation for evaluation prior to the start of
clinicals. Submit this documentation to the USA CON
Clinical Affairs department through your USA
Faculty.
Children’s Hospital Medical Practice
Corporation
New Orleans, Louisiana
Children’s Hospital of Alabama
Birmingham, Alabama
Children’s Hospital of the King’s
Daughters, Inc.
Norfolk, Virginia
Nursing Preceptor & NP Agreement
Exhibit A (along with other forms) to be completed by
faculty and student prior to placement. FACULTY,
PLEASE NOTE: Our one page agreement is not
required. Children’s Hospital of Alabama has a Form
of Preceptor Assignment (Exhibit 1.2) this form does
not require USA Faculty signature. Form Exhibit 1.2
will be accepted in lieu of our one page agreement.
USA does require a signed copy of Exhibit 1.2 for
our records.
NURSE PRACTITIONER STUDENTS ONLY
USA/Faculty: Provide a detailed description of the
objectives and specific fieldwork experience to be
provided in the program and any other information
required by facility within 30 days of clinicals. USA
responsible for Blood Borne Pathogens post
exposure follow-up.
NP
Student: Will complete the student profile
attachment.
Agency Contact:Linda Grasmick
Nursing Practice and Education Department
757-668-8463
linda.grasmick@chkd.org
Children’s Hospital of Wisconsin
USA Faculty: Must complete Exhibit A-Student
Placement Certification. Submit to facility the written
education Program objectives that will contain:
~academic content and nature of anticipated clinical
experience
~qualifications of its faculty and students as needed
for the clinical experience
~anticipated schedule of the clinical experience and
(renewal request sent, set to expire
5/31/2016)
Milwaukee, Wisconsin
17
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
USA's attendance policy
~educational responsibilities of USA and facility as it
applies to agreement
Children’s Medical Center of Dallas
Dallas, Texas
BSN, MSN, DNP
Student: Exhibit A-Student Certification. Must
complete the Wisconsin Caregivers Background
Check and make available the results to the facility.
BSN, MSN, and DNP students.
USA must provide document letter to agency to
verify background, drug and good standing with the
University (see attachment).
Arrangements must be made with agency not less
than 6 months prior to the start of each academic
term. USA must provide agency with written
information at least 2 weeks prior to clinical (name of
students and preceptor, objectives of practicum,
days, hours, and units.
Students must sign and submit to agency’s Waiver
and Release of Medical Liability, (Exhibit D). Provide
proof of Texas license and/or certification.
Children’s Med Services, Florida
Department of Health
Panama City, Florida
Children’s Mercy Hospital and
Clinics
Kansas City, Missouri
Children’s Rehab Services
Mobile, Alabama
Christian Medical Ministry of South
Alabama
Mobile, AL
Christus Health Northern Louisiana
Shreveport, Louisiana
Christus Santa Rosa Health Care
San Antonio, Texas
Christus Spohn Health System
Corp.
Corpus Christi, Texas
Christus St. Frances Cabrini
Hospital
Alexandria, Louisiana
Christus St. Patrick Hospital
RN-BSN, MSN, DNP
BSN, RN-BSN, RNMSN
Undergraduate
RN-BSN, MSN, DNP
Graduate Nursing
BSN, RN-BSN, MSN,
DNP
USA faculty must submit schedule indicating number
and names of students three weeks prior to clinicals.
(renewal request sent, set to expire
8/19/2016)
Lake Charles, Louisiana
Christus-St. Vincent Regional
Medical Center
Santa Fe, New Mexico
Faculty must provide facility with written
curriculum, evaluation methodologies and a set
of Student objectives and complete Exhibit A.
BSN, MSN, DNP
18
USA/Faculty: Provide Facility with a written
curriculum, evaluation, methodologies, and a set of
Student objectives. Provide a schedule for Students
specifying hours, days of the month, months of the
year during which Student will be in clinicals (Exhibit
A). Notify Facility within 48 hours when/if Student
becomes excluded from a federal health care
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
program.
USA/Faculty: Provide roster of names of the
designated Instructors and Students along with a
rotation schedule to person designated by Facility at
least two weeks prior to clinical experience.
Choctaw Nation of Oklahoma Health
Services Authority
Talihina, Oklahoma
Student: Provide verification of Tetanus in last 10
years or booster of TDaP. Negative urine drug
screen. Must have a current BLS certification for
adult, child, and infant. Encouraged to maintain
medical coverage.
Cincinnati Children’s Hospital
Medical Center
Cincinnati, Ohio
Faculty and Students please see Exhibits B & C
for agency requirements.
Also please note, student must complete and
sign (if applicable) the following:
Confidentiality Agreement
System Access Confidentiality Agreement
Patient Protected Health Information Access
Designation
Student Orientation Manual Receipt
Certificate of Completion for HIPAA Training
Course provided by CCHMC
This agreement is ONLY in effect for
Cincinnati Children's Hospital Medical
Center employees.
Citrus County Health Department
Lecanto, Florida
City of Hope National Medical
Center
Duarte, California
BSN, RN-BSN, RNMSN
USA/Faculty: Provide list of specific courses and
course objectives and desired units for placement at
facility. Provide 60 days prior to commencement of
experience or semester, the number and level of
students to be assigned to facility for clinical
experience. This will be subject to approval by facility
prior to experience. Provide evidence of student
health status to Hospital before the beginning of the
rotation. Such evidence shall include, without
limitation: the results of an annual physical exam;
negative two step tuberculin skin test; IGRA blood
test or negative chest x-ray if skin test is positive,
and proof of positive skin test; evidence of immunity
against varicella, mumps, rubella and rubeola; and
proof of current Tdap and Hepatitis B vaccination.
SEE OSHA Requirements, via attachments in
Sakai.
Student: Facility requests students to submit
information related to their prior experience, to
include job or level of experience descriptions and
specific information regarding competency. Must
have annual physical exam. Must provide evidence
of health insurance coverage. Familiarize
themselves with the foregoing privacy and security
laws and facility policies applicable to health
information. Provide written clearance from physician
before resuming participation in experience if
returning after an absence caused by injuring or
significant illness greater than 3 days of off-duty.
19
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Clay County Medical Corporation
d/b/a North Mississippi Medical
Center-West Point
West Point, Mississippi
NP
Must complete the Student Clinical Education
Agreement. Must complete Healthcare Criminal
History Background Affidavit. Must provide signed
affidavit that he/she does not have a disqualifying
event under the law or submit to fingerprinting in
order to comply with the requirements of Mississippi
Code (See Health Sciences Advisory form). Each
student shall submit proof and be considered
immune by providing the following: (1)
Documentation of having received two live measles
containing vaccinations after their first birthday, (2)
documentation of initial two step and up to date TB
skin test followed by annual
testing, (3) documentation of three Hepatitis-B
vaccinations or in process, (4) documentation of
having received a tetanus containing vaccination
within the past 5 years and a prior
tetanus/diphtheria/pertussis (5) documentation of flu
vaccine October-March or alternatively require
student to sign a waiver and wear a mask when in a
NMHS owned or operated facility. Medical
contraindications to vaccines and positive TB skin
test follow-up must be reviewed by NMMC-West
Point-Tupelo Employee Health.
Each student enrolled in the Clinical Education
Program will not be an employee of NMMC-West
Point within the meaning of the Mississippi Workers'
Compensation Law, and will not be receiving any
monetary compensation from NMMC-West Point
during the time of the training at NMMC-West Point;
Cleveland Clinic Florida
Weston, Florida
RN-BSN, MSN, DNP
USA/Faculty: Please see Protocol for Practicum and
Preceptorships. Please note and keep a record of
the student’s completion (date and time) of Exhibit E
(video) and submit to Beth in the Clinical Affiliations
office.
Students: Must complete and/or review Exhibits A-G,
CCF Code of Conduct, CCF Infection Control, CCF
Stroke Education, and Orientation packet (to include
Exhibit E, video the date and time must be reported
to your USA Faculty). Obtain and maintain a policy of
health insurance coverage providing basic medical,
surgical, and hospitalization benefits. Have received
instruction on standard precautions in accordance
with the requirements of OSHA. If Hep B vaccination
is declined the Student shall be required to sign a
form indicating that they are aware of the virus.
Coastal Family Health Center
Biloxi, Mississippi
Coliseum Medical Center
Macon, Georgia
Collaborative Care Services, Inc.
(Optum Health)
also covers (Southwest Medical
Associate clinics including urgent
care in Southern NV)
West Chester, Ohio
BSN, RN-BSN, MSN,
DNP, FNP
Faculty: please call Ms. Chris Maurice at 228974-2494 xt. 1019 to coordinate preceptor.
BSN, RN-BSN, MSN,
DNP
BSN, RN-BSN, RNMSN
20
USA/Faculty: See Exhibit A for Roles of USA per the
agreement. Provide written objectives to facility.
Notify agency of student’s hours in clinicals.
Student: Must Read and Sign Exhibit B. Facility will
provide for the orientation of students to its rules,
regulations and policies.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Columbia County-Florida
Department of Health
Lake City, Florida
Comanche County Hospital
Authority
Lawton, Oklahoma
Commonwealth Health Corporation
Bowling Green, Kentucky
MSN, DNP
Community CarePartners, Inc.
Asheville, North Carolina
BSN, RN-BSN, MSN,
DNP
USA/Faculty: Provide a schedule naming the
students to attend and planned attendance dates to
facility (Marjorie Rigdonmarjorie.rigdon@flhealth.gov-386-758-1334).
USA/Faculty: Provide clinical instructor name and
student roster at least10 days prior to clinicals. On
site instructors must have unrestricted license in
Oklahoma.
Student: Must have negative drug screen performed
by a laboratory licensed by the Oklahoma State
Department of Health. Students cannot perform any
of the following: double-check on medications or
blood products; or begin or discontinue blood
product, chemotherapy, ore experimental drugs and
therapies. Cannot accept orders from physicians or
other health care professionals in person or by
phone.
USA/Faculty: Provide names and social security
numbers of each student to Agency. Agency contact:
Trish Tison-phtison@chc.net.
Student: Must attend either the CHC New Employee
Orientation, Abbreviated Employee Orientation
program. Must complete a Student Application,
Statement of Understanding and any other
applicable documents provided by Agency to the
CHC Human Resources Department.
Recommended to obtain health insurance.
USA Faculty: Please see Appendix I, if instructing
students at agency. Provide written notice to agency
of practicum and affiliation assignments at least 60
days prior to clinicals. Develop and implement a
program for post exposure evaluation and follow up.
Students: OSHA required education in bloodbore
pathogens, personal protective equipment, and other
measures designed to avoid exposure to bloodborne
pathogens. TB test completed on annual basis.
Community HealthCare
Tacoma, Washington
Community Health Network (to
include: Community Hospital North,
BSN, RN-BSN, MSN,
DNP
BSN, RN-BSN, RNMSN
Community Hospital East, Community
Hospital South, and Community Home
Health).
Indianapolis, Indiana
USA/Faculty: Provide facility with the anticipated
number, type of schedule planned, kind of
educational experiences desired and academic
status of students. Facility must approve the number
of placements and scheduling of students. Must
provide any other pertinent information requested by
facility. Responsible for documentation of students
yearly participation in education concerning OSHA
Tuberculosis, OSHA Blood Borne Pathogens, CPR
and any other educational component as requested
by facility. Agency Contact: Jaima Foresman-317621-7973.
Student: Provide evidence of physical examination
showing good general health, coverage of health
insurance policy, proof of immunizations, current
(yearly) results of tuberculosis (skin test and/or x-ray)
tests assuring the student is free from active
infection of TB, proof of Hepatitis B immunization or
documentation showing student has been informed
of the risk of Hepatitis B and declined immunization.
21
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Community Medical Centers Fresno
(to include: Community Regional
Medical Center, Clovis Community
Medical Center, Fresno Heart and
Surgical Hospital)
Conemaugh Memorial Medical
Center
Johnstown, Pennsylvania
APRN
MSN, DNP
Must sign a confidentiality agreement as provided
and required by facility.
USA/Faculty: Clinical experience dates, names of
students, student’s bio info, objectives, and summary
of academic components of the curriculum
completed by student should be provided to the
Agency at least 30 days in advance. Contact: Joeal
Venkatesan-jvenkatesan@communitymedical.org.
Student: Must have Attachment A and Exhibit A
completed.
2015 UPDATE: FBI Clearance has been added to
the requirements. Please see additional
information on this link
https://www.pa.cogentid.com/index.htm.
Update: New policies affecting Conemaugh
Health System employees and CHS affiliating
schools students have been implemented.
Please send all clearance letters to:
Diane Kennedy, HR Assistant, HR
Dept.
Dkenned2@conemaugh.org
Effective, December 2, 2014
TB screening requirement (within 30 days prior
of student start date) – (1) Negative 2-step skin
test or blood assay test if not previously done or
not done yearly. OR (2) If done yearly – negative
skin test results for prior 2 years or negative
blood assay test for prior year. OR (3) If
previously positive, a completed TB symptom
questionnaire and clear chest x-ray, if indicated.
Online courses: HIPAA, MMC Infection
Control, MMC Ideal Patient Experience –
Access instructions attached.
Attachments:
Updated clearance letter templates. Please
use these letters from this point forward.
CHS TB Policy for employees and students
Updated Conemaugh Corporate Care Student
Fees
Instructions and link to access MMC online
education
Effective, July 1, 2014, these additional health
tests are now included in the affiliating schools
student clearance process: Influenza
vaccineo If student start date at CHS is during
flu season, 10/1 - 3/31, student must have
vaccine before starting their rotation.o If student
start date at CHS is outside of flu season,
student must acknowledge CHS influenza policy
and agree to be immunized by 11/15 of each
year. Policy allows exemptions for both medical
and religious reasons. More information to come
on the exemption process. Mumps
immunization (if rubella/rubeola vaccination is
needed) For clinical students with risk of
exposure to blood borne pathogens: Hepatitis
B: Must have immune titer or be
22
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
immunized. For students rotating in
Maternity/Nursery, NICU, Pediatrics, or
DEM. Tdap – receive one time dose of Tdap if no
written documentation of previous immunization.
Connecticut Children’s Medical
Center
Hartford, Connecticut
Connecticut Mental Health Affiliates,
Inc.
Nursing
USA/Faculty: Provide Hospital names of all students
beginning clinicals. Must notify unit supervisor as far
in advance as possible, but no less than twenty-four
hours in advance, when students will not or cannot
participate in clinicals. Must provide sufficient copies
of course materials to supervisor of the units. Verify
in writing for each student has had a health
examination, 2 step PPD, 5 panel negative urine
drug screen, rubella, rubeloa, and varicella zoster
titers from a federally approved site. Provide in
writing student has CPR certification. Must provide
all students with HIPAA and infection control
education.
MMC does not permit discharged employees to
return to MMC in an affiliating school instructor
role nor in a student role
Student: Must have Criminal History Record Check
completed and cleared within the last year before
clinicals. Must have child Abuse clearance within the
past year before beginning clinicals. Recommended
student purchase a health insurance policy. Must
sign Exhibit A.
USA/Faculty: Complete Exhibit B-Attestation,
Provide Agency with list of number and name of
students, along with name of Instructor.
Student: Complete Exhibit A-Confidentiality
Agreement. Students s have a background check
that includes (i) a criminal history including felonies
and misdemeanors for each state in which the
student has lived, worked, or attended school; (ii)
national sex offender registry check; and (iii) FACIS
Level III sanction check (the “Background Check”), at
the expense of each Student, performed no more
than forty-five (45) days prior to the start of the
academic year in which Student will complete the
Clinical Practicum at Connecticut Children’s.
BSN, RN-BSN, MSN,
DNP
(renewal request sent, set to expire
6/6/2016)
New Britain, Connecticut
Cook Children’s Hospital (to include
the Physician Network)
Fort Worth, Texas
Cookeville Regional Medical Center
Cookeville, Tennessee
Cooley Dickinson Hospital
Northampton, Massachusetts
USA/Faculty: Please see Exhibit A Background
Check/Drug Screen for agency requirements per the
agreement.
BSN, RN-BSN, MSN,
DNP
MSN, DNP
23
USA/Faculty: Provide all necessary details regarding
student to agency no less than six (6) weeks prior to
the beginning date of each clinical.
Student: Must be covered by a health insurance
policy. Must be current on all immunizations, to
include but not limited to, three doses of hepatitis B
vaccine or a positive hepatitis B titer and for a clinical
experience during October 1-March 31 of any year
under this agreement the student has received flu
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
vaccine within the prior 12 months. Must have
background check no later than three (3) months in
advance of the date on which the clinical experience
is scheduled.
USA must provide agency with clinical training
manual that details the goals and objectives of each
clinical rotation. Also USA faculty must provide
agency with student info and training guidelines no
fewer than 14 days prior to clinical.
Coolidge Emergency Group, LLC
(in conjunction with the Lafayette
General Medical Center agreement)
Morgan City, Louisiana
Cooper University Hospital
Camden, New Jersey
Cornerstone Health Care, P.A.
High Point, North Carolina
Corpus Christi Medical Center (Bay
Area Healthcare Group, Ltd.)
Corpus Christi, Texas
NP
Correct Care Solutions, LLC
(corporate office)
Psych NP Only
Attachments to be completed by faculty and student
BSN, RN-BSN, MSN,
DNP
MSN, DNP
(renewal request sent, set to expire
8/31/2016)
Nashville, Tennessee
USA/Faculty- please see the EMR agreement for
reference to the student completing Exhibit 1.
Students- Must complete and sign Exhibit 1.
USA/Faculty: Must complete Attestation Form
(Exhibit C) prior to student beginning clinicals (
Facility contact: Jennifer
Pyle jennifer.pyle@hcahealthcare.com). USA must
ensure that student trained in accordance with the
OSHA's Occupational Exposure to Bloodborne
Pathogens, and trained in the modes of
transmission, epidemiology and symptoms of
Hepatitis B virus and HIV.
Student: Must sign Statement of Responsibility
(Exhibit A) and Statement of Confidentiality (Exhibit
B). Must have had a TB skin test within the past 12
months or documentation as a previous positive
reactor or a chest x-ray within the past 5 years
and/or blood draw quantiferon within the past 12
months. Proof of Hepatitis B immunization or
certificate of declination of vaccine. Facility must
have access to the background investigation.
Background check must include the Texas HHS List
of Excluded individuals.
USA/Faculty and/or Student: Must provide a
clinical assignment schedule of dates, student
names, student date of birth and SS# (this is
for the purpose of the agency completing a
background check) for affiliation periods
throughout the academic year.
Student: Complete Waiver and Release.
Contact the CNO for onboarding process.
Covenant Hospice
Daphne, Alabama
Pensacola, Florida (corporate ofc.)
BSN, RN-BSN, MSN,
DNP
Covington Women’s Health
Specialists, LLC
Covington, Georgia
Cox Health (includes Lester E. Cox
BSN, RN-BSN, MSN,
DNP
BSN, RN-BSN, MSN,
24
Student must have confidentiality statement
signed and witnessed. Flu vaccination (Nov.1stMarch 31st). TB Symptom Staff Questionnaire
and no evidence of persistent cough.
Background check less than one year old. Drug
Screen less than one year old. Must complete
Student Intern Data Record available from the
contracts office. Faculty, please see updated
Student Intern Data Record.
Faculty and student review exhibit A.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Medical Center)
Springfield, Missouri
DNP
Cullman Regional Medical Center
Cullman, Alabama
Cumberland County Health
Department
Fayetteville, North Carolina
Cumberland County Hospital
System, Inc. d/b/a Cape Fear Valley
Health System
Fayetteville, North Carolina
RN, RN-BSN, MSN,
DNP
Students must be trained in compliance with
OSHA Blood-Borne Path regulations. Students
must show proof of the following: HEP B
immunization status or signed declination of
vaccine, they have received an appropriate TB
screening for TB disease as defined by CDC
guidelines. If practicum involves food service,
student must show proof of HEP A vaccination,
Tdap vaccination, MMR immunity or
vaccination, Varicella immunity or record of
vaccination series, where applicable students
must have influenza vaccination at least 15
days prior to clinicals. Student must submit to a
urine drug screen prior to clinicals.
BSN, RN-BSN, MSN,
DNP
BSN, MSN, DNP
Students must complete Appendix 1 prior to
beginning clinicals. Faculty, please contact CON
contract office for appendix. Agency Contact: Ruth
Doyle- rdoyle@cafefearvaley.com
D
DSHS Mental Health Division
(Western State Hospital)
Olympia, Washington
USA/Faculty: May be required to submit the following
information to facility: beginning and end dates of
clinical, number of students, specific days, hours,
and locations, learning objectives, performance
expectations for students, deadlines and format of
the progress report and/or evaluation forms. Must
provide curriculum and the professional and
academic credentials of its faculty for the students.
Student: Must have yearly PPD TB testing or followup if student is ppd-positive. Must have background
record from the Washington State Patrol and provide
to facility.
DSHS Rusk State Hospital
Rusk, Texas
Student: Must obtain health and
accident insurance policy and provide
verification of coverage to facility.
For each student participating in the program, University
shall require the student to submit fingerprints through
the Fingerprint Applicant Services of Texas
(FAST) form for a Texas/FBI criminal history check
and obtain a pre-assignment criminal history, nurse aide
registry and employee misconduct registry clearance
that ensures compliance with 25 Tex. Admin. Code
§414.504(d), which prohibits a DSHS facility from
25
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
allowing an individual to be employed by, assigned
volunteer status at, or serve as a professional clinical
intern at the facility who has been listed as revoked in
the Nurse Aide Registry (maintained by the Department
of Aging and Disability Services), listed as unemployable
in the Employee Misconduct Registry (maintained by the
Department of Aging and Disability Services), or
convicted of any offense identified on Attachment A,
which is incorporated by reference and made a part of
this Contract. All costs associated with the criminal
history and registry clearances shall be paid by the
University or by the student. This information
shall be used to determine if an offense
may be a prohibition or contraindication to
students being eligible to participate in the
clinical rotation at the Facility. Students
who have not passed the criminal
background check will not be permitted on
Facility premises.
Danita’s Children
Nashville, Tennessee
Dayton VA Medical Center
Dayton, Ohio
DCH Hospital Authority (includes
Fayette Medical Center, Northport Medical
Center)
Nursing
MSN, DNP
BSN, RN-BSN, MSN,
DNP
Tuscaloosa, Alabama
Deaconess Health System, LLC
Oklahoma City, OK
Deaconess Hospital, Inc.
Evansville, Indiana
Dekalb Medical Center
Decatur, Georgia
Denver Health and Hospital
NP
Nursing
RN-BSN, MSN,
DNP, NP
MSN, DNP
26
MSN and DNP Programs.
USA/Faculty: Annual Report of Influenza
Immunization Rate to be completed by Clinical
Affairs. USA must submit request four weeks prior to
clinical start date.
Student will need to sign the Acknowledgement
Form of the Policies and Procedures (available from
Facility). If student is placed in Facility for more than
12 months they will need to provide proof of a
negative TB skin test annually.
USA/Faculty: Please see addendum 1 for Patient
Care Duties To Be Provided By Students. Students
must have OSHA Training.
Student: Must complete Addenda 4&5. Must have
negative RB skin test within the past year or if a
positive TB skin test a chest x-ray within the past 3
years. Must have health insurance during their
clinical experience.
See Exhibit A for Program Requirements
Contact: Belle McCool belle.mccool@deaconess.com 812-450-2116
USA/Faculty: Provide names and phone number of
student’s faculty. Provide description of the expected
clinical educational experience including activities
and objectives for the program, roles for the clinical
experience and clinical department assignments.
Provide a skills checklist or formal validation of the
Students’ competency in performing the skills
required in the clinical education experience upon
request.
Student: Must participate in Hospital orientation.
Student: Must complete Hospital orientation.
Term for each student must be agreed upon at least
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Authority
Denver, Colorado
Doctors Hospital of Sarasota
Sarasota, Florida
Doctors Medical Center of Modesto,
Inc.
Modesto, California
Dominion Hospital
Falls Church, Virginia
RN-BSN, MSN,
DNP
(1) one month prior to the start of clinicals in writing.
Faculty must send facility the name of each Student
enrolled in clinicals, along with the Attestation
Letter (available from the contract office) 30
days prior to clinicals (to provide evidence of:
Immune status for Measles, Mumps, Rubella, and
Varicella for Measles, Mumps, Rubella must
provide evidence of two doses of MMR vaccine if
born after 1957, or positive measles, mumps,
rubella titers) and has completed immunization
for Hepatitis B or letter of declination on file
prior to the beginning of clinicals. Students that work
with 12 month olds or younger shall be required to
furnish regarding immunizations and booster
protection against pertussis. Student must have had
a PPD test in the past year. If student shows a past
history of positive TB skin test, must show evidence
of an annual assessment to rule out active TB.
Students must have received annual influenza
vaccine or declination on file. Seasonal influenza
vaccination is required of all Students rotating at
facility between October and March of each year.
Students must obtain Workers Compensation
Insurance through facility at the Student’s
expense. Students must carry health insurance
coverage under an accident and sickness health
insurance plan. Students must be 18 years or older.
USA/Faculty: Must complete Exhibit C-Attestation
Form.
Student: Must complete Exhibits A&B. Must pass
medical examination acceptable to Hospital.
BSN, RN-BSN, RNMSN and NP
USA/Faculty: Provide adequate
documentation attesting to competency of
each instructor, as appropriate.
Student: Must sign a Statement of
Responsibility (Exhibit A), and a Statement of
Confidentiality and Security (Exhibit B). May be
requested to obtain Professional Liability
Insurance above the amounts that USA
provides. Must pass a medical examination at
least one year prior to clinicals, or otherwise
required by Virginia law. Annual flu vaccination
(proof of flu vaccination October 1st-March
31st) as required by Hospital policy. Hospital
may, at its discretion, conduct an alcohol test
on Students.
Driscoll Children’s Hospital
Corpus Christi, Texas
MSN, DNP
Duke University Affiliated
Physicians, Inc.
27
Students must complete Exhibits A & B prior to
beginning clinicals. CON must complete Exhibit C on
behalf of student. Effective Flu Season 2011, the
Influenza Vaccine is MANDATORY for all program
participants (instructors and students). Exhibit C
must be completed prior to beginning clinicals.
Student will not be permitted on-site without
documentation verifying Criminal Background Check
and Immunization status & signed Confidentiality
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Statement on file. Student will need to complete
Compliance and Safety Training and have current
CPR certificate. Faculty should contact Contract
person at CON regarding student’s paperwork.
Student will not be permitted on-site without
documentation verifying Criminal Background Check
and Immunization status & signed Confidentiality
Statement on file. Student will need to complete
Compliance and Safety Training and have current
CPR certificate. Faculty should contact Contract
person at CON regarding student’s paperwork.
USA must complete and sign the Trainee
Qualifications and Credentials Verification Letter
(TQCVL) for each student (available in Pub Docs or
from the Clinical Affairs Department).
Durham, North Carolina
Duke University Health System, Inc.
Durham, North Carolina
Durham VA Medical Center
Durham, North Carolina
Dyersburg Regional Medical Center
Dyersburg, Tennessee
BSN, RN-BSN,
MSN, DNP
USA/Faculty: Provide written documentation
on: student’s immunizations, to include TB skin
test within past year or if positive test, chest xray within the past 3 years, completed series of
Hepatitis-B vaccine, or informed refusal of the
vaccine. Legal required testing as written in
Addendum 3, Provide facility with each
Student’s completed:
Substance Policy Consent Form (Addendum
4).
Background Consent Form (Addendum 5).
Copy of forms must be on file at facility before
student may begin clinicals.
Student: Must adhere to Substance Policy.
See Addendum 4. Must have health insurance
during clinicals at facility.
E
E.A. Roberts Alzheimer’s Center
Mobile, Alabama
East Alabama Medical Center and
EAMC Lanier
Valley, Alabama
East Cooper Medical Center
Mount Pleasant, South Carolina
BSN, RN-BSN,
MSN, DNP
RN-BSN, MSN,
DNP
*Student and Preceptor must view videotape
regarding Hospital's patient information privacy
policies and practices provided by Hospital.
Verification must be sent to USA Clinical Affairs
Office-Beth Collier -ecollier@southalabama.edu for
recordkeeping purposes.
USA/Faculty: Complete Exhibit C-Attestation.
Student: Complete Exhibits A& B. Must secure
health insurance coverage.
East Jefferson General Hospital
NURSING
28
Education Contact:
David Potter
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
CME/GME Coordinator, EJGH
Phone: (504) 503-4283
Email: dpotter@ejgh.org
Metairie, Louisiana
East Tennessee Children’s Hospital
Knoxville, Tennessee
Eastern Idaho Health Services
Idaho Falls, Idaho
Eastern Maine Medical Center
Bangor, Maine
Eastern Virginia Medical School
(EVMS) Department of OB/GYN
Norfolk, Virginia
MSN, DNP
Faculty needs to provide roster of students, etc.
*Students must submit a letter to CNO regarding
goals outlined by the school and the student for the
practicum and a copy of the student’s current vitae.
*Graduate students must be interviewed by EJGH
oversight committee members to discuss mutual
goals and objectives.
*Students must have preceptor selected by Director
of CNKR and meet with preceptor prior to starting
practicum.
USA/Faculty: Must provide training and education
programs to all students on the OSHA/Blood Borne
Pathogens.
Students: Must have a health insurance policy in
effect.
BSN, MSN
MSN, DNP
Ector County Hospital
District/Medical Center Health
System
Odessa, Texas
Edward Hospital
Elmhurst, Illinois
MSN, DNP
Edward W. Sparrow Hospital Assoc.
Lansing, Michigan
MSN, DNP
29
Student: Must obtain/maintain ALL liability insurance
coverage (Students, shall obtain and maintain at all
times professional liability insurance with limits
sufficient to meet the maximum amount recoverable
as set forth in Virginia Code Section 8.01-581.15 as
amended, or any successor statute thereto, per
occurrence and three (3) times the maximum amount
set forth above in the aggregate annually. If the
policy is of a claims made type, such policy shall
provide for a retroactive date that is no later than the
December 15, 2015 and, upon termination or
expiration of this agreement, coverage shall continue
until the expiration of the applicable statute of
limitations period for the activities undertaken by
Facility and Institution hereunder, but in no
circumstances for less than two (2) years). Must
provide a certificate of coverage to the Facility
and University, prior to the beginning of clinical
experience.
Must obtain and maintain health insurance coverage.
Student must have health/accident insurance.
Students must have TB test and/or chest x-ray
results taken within the previous 6 months.
Drug/alcohol screening within the previous two
weeks. USA must verify that each student has
been cleared through the background check and
drug/alcohol screening processes. Upon request
student must release background check and
drug/alcohol screening results to Facility.
Student: Must maintain comprehensive health
insurance. Obtain prior written approval of the
Facility before publishing any material relating to the
clinical experience.
USA/Faculty: At least one month prior to clinicals
provide curriculum, program description, objectives,
semester dates, student names, work schedules,
name of faculty coordinators, and preceptors.
Students: Must complete Exhibits A-C.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Eglin Air Force Base, 96th Medical
Group/SGSF
Eglin AFB, Florida
BSN, RN-BSN,
MSN, DNP
Eliza Coffee Memorial and Shoals
Hospital
Florence, Alabama
Elliot Health System
Manchester, New Hampshire
Nursing
Undergraduate and graduate nursing degree
programs– Students must sign the Trainee
Agreement Addendum. Faculty and/or Students
must contact Sherri Prejean at 850-883-8080 or
sherri.prejean.ctr@eglinaf.mil prior to beginning of
clinicals for approval.
Students: Complete Exhibit A & B.
BSN, MSN, DNP
USA/Faculty: Must provide clinical practicum
objectives to facility. (Deborah Langton - 603663-2715).
Student must complete Confidentiality
Agreement through agency.
MSN Students
Emergency Medicine Associates,
P.A., P.C. (in conjunction with the
Novant Prince Williams Medical
Center)
Germantown, Maryland
USA/Faculty: Submit a written request at least 6
weeks prior to clinicals indicating the number of
students, length of time and dates, proposed days
and hours. Provide evaluation forms. Provide
educational program(s) for Students regarding
OSHA compliance standards prior to clinicals.
Provide Facility with name and telephone number of
USA Faculty, who shall plan with facility staff clinical
experience (Wendy Walkerwwalker@emaonline.com).
Student: Must have health insurance coverage.
Provide documentation of PPD or CXR within one
year and evidence of inoculation for Hepatitis B or
signed declination.
Emergency Physicians of Central
Florida, LLC
Orlando, Florida
Escambia County Alabama
Community Hospitals, Inc., d/b/a
Atmore Community Hospital
(Infirmary Health)
Mobile, Alabama
Essentia Institute of Rural Health
Duluth, Minnesota
BSN, RN-BSN,
MSN, DNP
NNP STUDENTS
ONLY
(Minnesota sites should only
be utilized by approved USA
students)
Evans Army Community Hospital
Fort Carson, Colorado
Evanston Clinic Corp.
Evanston, Wyoming
Student must complete the Confidentiality
Statement.
USA faculty will need to reference Essentia
Health's website at
http://www.essentiahealth.org/for_vendors.
html to review the Code, its updates. USA
faculty must provide program objectives to
agency.
MSN, DNP
USA must send names of students, dates & hours
requested 60 days prior to clinicals to agency.
MSN, DNP
USA/Faculty: Please see Addenda 1 & 2 regarding
Patient Care Duties. Report all appropriate
immunizations requested by Facility. Agency
Contact: Joshua Jones (307) 783-8364.
Student: Must complete Addendum #4 -Substance
Policy Consent Form and Addendum #5 -
30
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Background Consent Form. Must have health
insurance during clinical rotation at facility.
F
Fairfax-Falls Church Community
Services Board
Fairfax, Virginia
Fairview Health Services
Minneapolis, Minnesota
MSN, DNP
RN-BSN, MSN,
DNP
USA/Faculty: Supply the Facility with materials,
including instructional criteria for evaluating student's
performance. Upon request USA will ensure each
student placed at Facility completes a Student Profile
Sheet and a post clinical evaluation for the
Department of Staff Development and Training.
Students are recommended to have a onetime vaccination of Pertussis (t-dap).
(Minnesota sites should only
be utilized by approved USA
students)
Family Healthcare
St. George, Utah
Family Health Care Center
Saint Louis, Missouri
Fawcett Memorial Hospital
Port Charlotte, Florida
Florida Department of Health-Duval
County
Jacksonville, Florida
Fletcher Allen Health Care
Burlington, Vermont
Florida Department of Health
Lee County
Fort Myers, Florida
Florida Department of Health-Levy
County Health Department
Bronson, Florida
Florida Department of Health
Includes: Holmes County Health
Dept.
BSN, RN-BSN,
MSN, DNP
MSN, DNP
RN-BSN, MSN,
DNP
Graduate
Faculty, any correspondence with preceptors
must be copied to Mr. Dennis Kruse, CFO-401
Holly Hills Avenue, St. Louis, MO 63111-2410
Student: Must complete Exhibits A-C. Must pass a
medical examination acceptable to Hospital.
Student must complete Attachment A-Confidentiality
Agreement and submit to Yvette Andrews
(yvette.andrews@flhealth.gov) prior to clinicals.
MSN,DNP
RN-BSN, MSN, DNP
BSN, RN-BSN,
RN-MSN
BSN, RN-BSN,
MSN, DNP
(renewal request sent, set to expire
8/1/2016)
Bonifay, Florida
31
Agency contact: Yvonne McConnell-239-3329569-yvonne.mcconnell@flhealth.gov.
Student must provide a background check that
includes a fingerprint FBE and FDLE screening
that has been done within the last 5 years, prior
to beginning clinical.
Student must provide the agency with verification
they have met the requirements for vaccinations
and TB testing pursuant to the DOH policy.
USA must submit a schedule naming the students
to attend and the planned attendance dates
(Barbara Locke-352-486-5300 ext. 232barbara_locke@doh.state.fl.us).
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Student must provide a background check that
includes a fingerprint FBE and FDLE screening
that has been done within the last 5 years, prior
to beginning clinicals.
Florida Department of Health
Seminole County
Sanford, Florida
Florida Hospital Fish Memorial (SW
Volusia Healthcare Corp.)
Orange City, Florida
Florida Hospital North Pinellas
Tarpon Springs, Florida
Nursing
Student must provide the agency with verification
they have met the requirements for vaccinations
and TB testing pursuant to the DOH policy.
USA/Faculty: Changes in staff or curriculum affecting
either party shall be subject to immediate notification
of the parties.
Student: Each student shall attend all activities
involving the department assigned. Must have written
character references on file with USA. Provide facility
with all forms (if any) regarding practicum experience
and instruction for completion of forms.
USA/Faculty: Please complete the Student/Preceptor
Letter (fillable) and submit to Clinical Affairs for
signature, then return to Agency. Please provide a
copy of the objectives for the education experience
and any required forms regarding the practicum and
instructions for completion of these forms.
Student: Must complete the Hospital's
Acknowledgement for Confidential Information and
Protected Health Information Access form upon
orientation to the Hospital. Must have a Florida
Department of Law Enforcement Level 2 criminal
background check completed and provide results to
University and Hospital.
Floyd Healthcare Management
Rome, Georgia
Floyd Memorial Hospital and Health
Services
New Albany, Indiana
Forrest County General Hospital (to
include Marion General Hospital)
Hattiesburg, Mississippi
Fort Belvoir Community Hospital
Fort Belvoir, Virginia
RN-BSN, MSN,
DNP
Fort Smith HMA, LLC d/b/a Sparks
Health System
Fort Smith, Arkansas
MSN, DNP
RN-BSN, MSN,
DNP
Please see Exhibit C for any additional requirements.
MSN, DNP
Students: Must complete Trainee Agreement.
Students will be required to have an ACCESS
NATIONAL AGENCY CHECK and INQUIRIES
(ANACI) investigation with an IT-2 Level Designation
as they will have PHI and network access. This
includes but is not limited to a full background check
including fingerprinting. Student who will provide
health care to patients under the age of 18 on a
regular basis will submit to a state criminal history
repository (SCHR) check as indicated by the
Department of Defense Instruction 1402.5.
Nursing students wishing to participate under this
Agreement must contact Theresa Phillips in Human
Resources 479-441-5458 to set up an appointment to
begin the screening and orientation process.
Student must take Compliance test from agency prior
to beginning clinical rotation. Also exhibits must be
completed.–Agency contact: Richelle Kennedy, MSM,
Education Manager
Office,Richelle.Kennedy@HCAHealthcare.com.
Fort Walton Beach Medical Center
(renewal request sent, set to expire
6/11/2016)
Ft. Walton Beach, Florida
32
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Fox Army Health Center
Redstone Arsenal, Alabama
Franciscan Health System (to
include: St. Francis Hospital, St.
Clare Hospital, St. Anthony
Hospital, St. Elizabeth Hospital,
Highline Medical Center, Harrison
Medical Center and the Regional
Hospital for Respiratory and
Complex Care)
Tacoma, Washington
Franciscan Medical Group
Tacoma, Washington
Franciscan Pace, Inc.
Baton Rouge, Louisiana
Franklin Primary Health Center, Inc.
Mobile, Alabama
Frankfort Regional Medical Center
Frankfort, Kentucky
Freeman Health System
Joplin, Missouri
MSN, DNP
USA/Faculty: Require each student to complete
training and education (OSHA approved, where
applicable) on the following prior to clinicals: universal
precautions and infection control; body mechanics;
fire safety and disaster safety; HIPAA; any other
training identified by Hospital.
RN-BSN, MSN,
DNP
MSN, DNP
NP
Student: Must have physical examination to include
the following immunizations and tester as per CDC
guidelines: complete Hepatitis B vaccination series;
annual TB screening (including chest x-ray, if
applicable); MMR vaccination or positive titer;
varicella vaccination or varicella titer. Must complete
Attachment A-Student Participation Agreement and
Waiver and Attachment B - Consent for Student to
Submit and /or Alcohol Testing Authorization for
Release.
USA/Faculty: Please review the CHI Standards of
Conduct http://www.catholichealthinitiatives.org/corporateresponsibility. May be required to complete a
Clinical Site Information Form to indicate
information regarding the qualifications and
responsibilities of the facility coordinator. Facility
will provide.
Student: Must complete attachments A&B. Must
have completed training and education (OSHA
approved, where applicable) for universal
precautions and infection control, body
mechanics, fire safety and disaster safety, HIPAA
prior to clinical experience.
USA/Faculty: Prepare student assignments and
rotation plans for each student and coordination
of same with facility.
Student: Must complete and sign Attachment 1
Student Agreement, Attachment 2 Statement of
Responsibility, and Attachment 3 Statement of
Confidentiality prior to beginning clinicals. Must
have had a Tuberculin Skin Test within the past
12 months.
Nurse Practitioner Students
Student: Must sign a Statement of Responsibility
(Exhibit A), and a Statement of Confidentiality (Exhibit
B). Provide proof of Influenza vaccination during Flu
Season, Oct. 1 - March 31, (or dates defined by CDC,
or a signed Declination Form.
MSN, DNP
33
USA must provide a roster of student’s names
and clinical rotation schedule to agency.
Students must have a Missouri Background
Check to include the Missouri Employee
Disqualifications List and to comply with the
requirements and provisions of the Revised
Statutes of Missouri.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
G
Gadsden Regional Primary Care,
LLC
Nursing-Not NP’s
(renewal request sent, set to expire
8/24/2016)
Gadsden, Alabama
Gaston Health Care, Inc. d/b/a
CaroMont Health
Gastonia, North Carolina
Geisinger Health System
Danville, Pennsylvania
Genesis PrimeCare
Marshall, Texas
Gentiva Hospice
Columbus, Georgia
USA Faculty please see Addena 1-3.
Students must complete Addendum 4-Substance
Policy Consent Form and Addendum 5Background Consent Form.
CNS, CNL
Only for CNL and CNS Students
MSN, DNP
USA/Faculty: See Exhibit A-Teacher/Learner
Expectations. Request from Agency (Barbara
Kallbach - bakalbach@geisinger.edu
570 271 6114 option 0) and complete
Implementation Letter per each student.
Students: Must maintain health insurance and
provide proof of health insurance to USA. May be
required to undergo a drug test or similar screening
test pursuant to the agency's policies and practices,
cost of such screening will be paid by the student.
RN-BSN, MSN,
DNP
MSN, DNP
George E. Wahlen Department of
Veterans Affairs Medical Center
Salt Lake City, Utah
George Regional Health Systems
Lucedale, Mississippi
Georgetown University Hospital
Washington, D.C.
BSN, MSN, DNP
Georgia Regents Medical Center
Augusta, Georgia
Nursing
Student: Must have background check that is in
accordance with any and all applicable state and
federal law Caregiver Background Check Law on
each on-site Instructor (preceptor) and Student. Must
have OSHA training for universal precautions, blood
borne pathogens and tuberculosis control. Must
complete the Student Participation Agreement and
the Patient Permission For Student Externship
forms.
Faculty must complete the facility’s Request for
Placement form and email to
Annette.Sanchez@va.gov at least 30 days prior
to beginning of clinical date.
BSN, RN-BSN,
MSN, DNP
MSN, DNP
34
The following items must be completed prior to
student beginning clinicals: Faculty provides syllabus
to CON contract office as Attachment A, Dean must
sign Attachment B, and student signs Attachment D.
USA/Faculty: Provide to Facility the number of
students, course of instruction, and dates of clinical
at least 14 days prior to clinical. Student must supply
Facility a written certification and attestation verifying
the student’s successful completion of HIPAA
training.
Student must sign written agreement obligating them
to observe all rules and policies established by
Facility and maintain the confidentiality of patient info
and refrain from publishing any material related to
the agreement that identifies or uses the name of the
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Board of Regents, or the Facility.
USA/Faculty: Facility must approve of clinical at least
one month prior. Provide upon request, student
records as will adequately disclose prior education
and related experience. Facility contact: Nicole Wells
newells@dhr.state.ga.us 404-212-4752.
Georgia Regional Hospital at Atlanta
Atlanta, Georgia
Student: Facility will provide orientation to students.
Student to follow CDC Standard Blood borne
Pathogens guidelines and OSHA Respiratory
Protection Standard (Facility will provide student with
education regarding blood borne pathogens
appropriate to students training at facility. Must sign
a confidentiality/HIPPA agreement. Must obtain and
maintain health insurance and provide proof of said
insurance to facility upon request. Student must
have health examination at time of clinicals to
determine they are free of any infectious or
contagious diseases. Student must sign Consent for
Release of Information form (attached) and submit to
facility.
Georgia Southern University
Statesboro, Georgia
Good Shepherd Medical CenterMarshall
Marshall, Texas
Gordon Oaks Health and Rehab
Mobile, Alabama
Gov. Juan F. Luis Hospital and
Medical Center
Christiansted, VI
Grace Medical Clinics, PA
Nurse Practitioner
Program Only
BSN, RN-BSN,
MSN, DNP
BSN, RN-BSN, MSN,
DNP
MSN, DNP
(renewal request sent, set to expire
8/11/2016)
Charlotte, North Carolina
Grady Health System
Atlanta, Georgia
Grandview Medical Center
Dayton, Ohio
Grandview Medical Group
Birmingham, Alabama
Graves Gilbert Clinic
Bowling Green, Kentucky
Greenville Clinic Corp.
Greenville, Alabama
Gulf Coast Medical Center
Panama City, Florida
MSN, DNP
MSN, DNP
Nurse Practitioner
USA/Faculty and Students: Please see Exhibits B-E,
for review and completion. Students notify faculty
prior to starting clinicals. Please see Clinical
Orientation Instructions.
The student may be required to complete an
orientation program with the facility. Also, the agency
may require a further background check that is in
accordance with the Ohio Bureau of Criminal
Identification and Investigation procedures.
USA/Faculty: See Addenda 1 & 2 for Patient Care
Duties provided.
Students: Must complete Addenda 3, 4 and 7.
RN-BSN, MSN,
DNP
RN-BSN, MSN,
DNP
BSN, RN-BSN,
MSN, DNP
35
Students: Complete Addenda 4 & 5. Must have
health insurance during clinical experience at
Facility.
Student must complete Exhibits A-C.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Gwinnett Hospital System, Inc.
Lawrenceville and Duluth, Georgia
Gwinnett Hospital System, Inc.
Lawrenceville and Duluth, Georgia
FNP Only
Gwinnett Hospital System, Inc.
Lawrenceville and Duluth, Georgia
NP
Gwinnett Hospital System, Inc.
Lawrenceville, Georgia
– Preceptor Dr. Phillip Cannon only.
Please see website for placement information:
www.gwinnettmedicalcenter.org.
FNP students only – preceptor Dr. Prasad
Garimella.
Faculty complete and Student review Exhibit “A”
Permitted Activities of the Student
Student orientation materials are now on our
website:
http://www.gwinnettmedicalcenter.org/programsclasses/GMCContentPage.aspx?nd=276
BSN, MSN, DNP
NP students only – preceptor Dr. Leslie Leigh;
Students must review Exhibit “A” Permitted Activities
of the Student
Student orientation materials are now on our
website:
http://www.gwinnettmedicalcenter.org/programsclasses/GMCContentPage.aspx?nd=276
BSN, MSN, DNP programs. The agency may at any
time request health status reports on students at
their facility. USA/Faculty and Students please find
placement information on the following website:
www.gwinnettmedicalcenter.org
H
Hackensack University Medical
Center
Hackensack, New Jersey
Halifax Health
Daytona Beach, Florida
RN-BSN, MSN,
DNP
Nurse Practitioner
36
USA/Faculty: Number of student to be assigned
must be in conformity with the New Jersey Board of
Nursing, a 1:10 instructor/student ratio. Must provide
written clinical objectives to the nurse manager
and/or staff nurse for all clinicals. Must notify agency
at least 2 months in advance of its planned clinical.
***Please see Influenza Policy and Requirements***
Student: Must have a negative 5 panel substance
abuse urine drug screen, within the past 12 months.
Must contribute/participate in the agency's Evidence
Based Practice and Research activities.
Graduate and RN to BSN students who have already
completed the clearance process for the fall
semester must contact Fran DeLuise (fdeluise@HackensackUMC.org)no later than
October 15th and provide documentation of vaccine
status. Moving forward graduate and RN-BSN
students are required to provide documentation of
vaccine status to the Department of Clinical
Education during the clinical clearance process prior
to beginning their clinical experience.
USA/Faculty: Please visit Facility website for student
internship application
https://www.halifaxhealth.org/about-us/humanresources/student-internships
Provide to Facility the current curriculum, course
objectives, and syllabus for each student's clinical
experience.
Student: Must have health examination as
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
required by Facility.
Hancock Medical Center
Bay St. Louis, Mississippi
Hany S. Aziz, MD, Inc.
Bakersfield, California
Harbin Clinic
Rome, Georgia
BSN, RN-BSN,
MSN, DNP
Hattiesburg Clinic, PA
Hattiesburg, Mississippi
Hawaii Pacific Health
Honolulu, Hawaii
BSN, RN-BSN,
MSN, DNP
MSN, DNP
MSN, DNP
Students must review Exhibit “A” Standards of
Conduct, USA must submit request for clinical and
the immunization documentation to agency’s
Coordinator (Stephen Bowman
stephen.bowman@hawaiipacifichealth.org) four
weeks prior to student placement.
USA must complete Exhibit A-Roster prior to
clinicals. USA is being asked to also provide, upon
request of Facility for Facility audit purposes,
documentation of student alcohol and drug testing.
BSN, RN-BSN,
MSN, DNP
Students must complete Exhibit A (Statement of
Responsibility) and Exhibit B (Confidentiality
Statement) prior to beginning clinical rotation.
Faculty, please send completed Attestation Form to
the hospital in which your student is using as a
clinical site.
Health Care Centers in Schools,
Inc., d/b/a Health Centers in Schools
Baton Rouge, Louisiana
MSN, DNP
Health Texas Provider Network and
Baylor University Medical Center
Dallas, Texas
Healthsouth Rehab Corporation
Mobile, Alabama
Heartland Regional Medical Center
d/b/a Mosaic Life Care
St. Joseph, Missouri
APRN
USA/Faculty: Facility contact: Sue Catchingss.catchings@ebrschoolhealth.org, Yolanda
Lastrapes - y.lastrapes@ebrschoolhealth.org, Sean
Nguyen - s.nguyen@ebrschoolhealth.org.
Students: Complete attachments 1-3.
Student: Must participate in the orientation provided
by the Hospital and Group. Must maintain adequate
health insurance throughout clinical experience.
Complete Confidentiality Agreement.
HCA Health Services of Tennessee,
d/b/a Centennial Medical Center
Nashville, Tennessee
HCA North Texas (includes Denton
Regional Medical Center, Green Oaks
Psychiatric Hospital, Las Colinas Medical
Center, Medical Center of Arlington, Medical
Center of Lewisville, Medical Center of
McKinney, Medical Center of Plano, Medical
City Dallas Hospital, North Hills Hospital,
and/or Plaza Medical Center of Fort Worth)
Irving, Texas
BSN, RN-BSN, MSN,
DNP
USA/Faculty: Provide a list of students and clinical
rotation schedule at least two weeks prior to the
beginning of experience.
Student: Must complete any orientation/training
required by Facility, document completion if
applicable
(https://www.mymosaiclifecare.org/students
).Must obtain health insurance. Must obtain a
Missouri background check pursuant to the
provisions of R.S. MO 660.317 prior to experience.
Background check recommendations can be found
at https://www.mymosaiclifecare.org/students.
At a minimum, each background check shall include
a review of the following:
37
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
High Point Regional Health
High Point, North Carolina
Highland Community
Hospital/Highland Physicians Clinic
Picayune, Mississippi
Holmes County Department of
Health
Bonifay, Florida
Honor Health (Scottsdale
Healthcare)
Scottsdale, Arizona
Hope Hospice and Community
Services, Inc.
Fort Myers, Florida
Housing First, Inc. (15 Place)
Mobile, AL
HSOC, Inc. (Children at Hughes
Spaulding)
Atlanta, Georgia
RN-BSN, MSN, DNP
MSN, DNP
●
Missouri Highway Patrol Criminal
Background Check
●
Other State Criminal Background Check
(previous residences other than MO/KS in past 7
years)
●
US Dept. of Health and Human Services
and the Office of Inspector General's database for
individuals and businesses excluded or sanctioned
from participating in Medicare, Medicaid, or other
federally funded programs
●
General Services Administration/Excluded
Parties List System
●
Missouri Sex Offender Registry
●
Other State or National Sex Offender List
(previous residences other than MO/KS)
●
Name, Social Security Number and
Address Verification
●
United States Treasury — SDN and
Blocked Persons List Web Site.
USA/Faculty: Complete Exhibit B. Provide objectives
for student’s clinical experience. Provide to Agency,
the names of students at least one month prior to the
beginning of experience.
Student: Completed Exhibit A-HIPAA Confidentiality
Agreement.
Please see Exhibit C for specific requirements.
Students are required to submit fingerprints to
agency. Students shall maintain comprehensive
healthcare insurance during clinicals.
MSN, DNP
MSN, DNP
BSN, MSN, DNP
MSN and DNP
See Requirements listed within Exhibits B-1 and C.
USA/Faculty: Provide Agency with overall objectives
of experience.
Student: Must sign Participant Agreement Tracking
Form. Please read Exhibit B-1 Participant
Agreement.
Hunt Regional Healthcare
Greenville, Texas
Huntsville Hospital (to include:
BSN, RN-BSN,
MSN, DNP
MSN, DNP
Huntsville Hospital (main), Huntsville
Hospital for Women & Children,
Madison Hospital, Parkway Medical
Center, and Heart Center, Inc. and
USA Faculty please visit the following website for
any clinical placement:
http://www.huntsvillehospital.org/schools-withclinical-affiliation.
Student must at their own expense have substance
abuse test to include, alcohol drugs, or controlled
38
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
substances immediately prior to student beginning
clinicals.
Athens-Limestone Hospital)
Huntsville, Alabama
Huntsville Memorial Hospital
Huntsville, Texas
RN-BSN, MSN, DNP
Huntsville Hospital's Emergency Department will not
be accepting clinical or precepting requests for Fall
2014 or Spring 2015.
USA/Faculty: Provide schedule indicating for time
period of clinical experience. See Clinical Checklist.
Student: PLEASE READ Program Participant
Agreement and Waiver of Claims before signing.
I
IASIS Glenwood Regional Medical
Center d/b/a Glenwood Regional
Medical Center
West Monroe, Louisiana
I.D. Group of Atlanta
Atlanta, Georgia
IHC Health Services, Inc.
(Intermountain Healthcare)
Salt Lake City, Utah
IMC Clinics ( to include: IMC Baldwin
Surgery, P.C., IMC Diagnostic & Medical
Clinic, P.C, IMC Family Medical of Jackson,
P.C., IMC Mobile Medical Group, P.C., IMC
Cancer Surgery of Mobile, P.C., IMC
Eastern Shore Adult Medicine, P.C., IMC
Family Medical of Mobile, P.C., IMC North
Baldwin Internal Medicine, P.C., IMC OBGYN Associates, P.C., IMC Pediatrics and
Adolescent Medicine, P.C., IMC Women’s
Health Alliance of Mobile, P.C., Infirmary
Health Urgent Care-Bay Minette, P.C., IMC
Foley Medical Clinic, P.C., North Baldwin
Family Medical, P.C. North Baldwin
Pediatrics, P.C.
MSN, DNP
Student must complete Exhibits A & B.
MSN, DNP
NP
BSN, RN-BSN,
MSN, DNP
39
From Intermountain’s Associate Chief Medical
Officer:
“The guidance from the CDC and our own
internal plan is to restrict the number of health
care workers who provide bedside care to a
suspected or confirmed Ebola patient. We are
assembling a team of experienced ICU staff who
would receive advances training prior to being
assigned to such a patient. …we [are] NOT to
assign nursing students, medical students or
other trainees to a suspected Ebola patient.”
Faculty, please report to Contract Office any
students at this facility during October-April each
year at end of clinical experience and if the
students Influenza Vaccination. (Only if student
was at any of their sites for 30 days or more).
Please see exhibit B for immunization
requirements.
Student-must have evidence of Hepatitis B
vaccination and/or positive antibody titer or
presentation of the OSHA declination form. Evidence
of Mantoux-two step TB skin testing or proof of a
previous positive result. Evidence of an annual TB
skin test of a previous positive result.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Mobile, Alabama
InPhyNet Contracting Services, LLC
InPhyNet Primary Care (3-way
agreement with Iberia Medical
Center)
Fort Lauderdale, Florida
INTEGRIS Health, Inc. (and
affiliated entities)
Oklahoma City, Oklahoma
Nursing
NP
Graduate Nursing
Programs
USA/Faculty: Provide course objectives and ensure
ongoing communication with Preceptor. Notify
Company and Preceptor of planned schedule of
each student assignment, including name of student,
level of academic preparation, and length and dates
of clinical.
Emergency Room Department Students – Iberia
Medical Center clinicals.
USA/Faculty: Must provide a roster of the names of
the USA Clinical Coordinator and Students and
rotation schedule prior to clinical.
Students must complete Exhibit A, Student
Confidentiality Agreement. Must have negative
tuberculin skin test (in conformity with the Oklahoma
State Department of Health’s guidelines) or negative
chest x-ray.
*Name Alert* Due to Hurricane Katrina, this site
has a new name (Louisiana State University
Interim Hospital). USA must provide learning
objectives prior to clinicals. USA must send letter to
Dept. Director with student’s health status.
USA Faculty, please submit attestation to; Rodney
Interim LSU Public Hospital (Charity
Hospital and Medical Center of
Louisiana at New Orleans)
New Orleans, Louisiana
Campbell 504-702-2068
or rodney.campbell@lcmchealth.org
InPatient Consultants of Alabama,
Inc. (in conjunction with the following:
BSN, RN-BSN,
MSN, DNP
Springhill Medical Center, Mobile Infirmary
Medical Center, and North Baldwin
Infirmary)
North Hollywood, CA
InPatient Consultants of Colorado,
P.C.
North Hollywood, CA
MSN, DNP
InPatient Consultants of Florida, Inc.
North Hollywood, California (Main
MSN, DNP
40
USA/Faculty: Provide to Medical Group (IPC), a list
of students and their desired dates who will be
participating in clinicals under the terms of this
agreement. Advise students in writing that their
participation in clinicals under Medical Groups
supervision is conditioned at all times to the
following:
All instructions given by the Provider who is
supervising the Student’s Clinical Rotations. All rules
and policies set forth by Medical Group and any
Facility with regard to Students’ participation in the
Clinical Rotation, including but not limited to,
maintaining the confidential nature of patientidentifying information that is disclosed to any
Student during their Clinical Rotation with Medical
Group; and, Applicable policies and procedures of
the Facility or Facilities where the Student is
participating in a Clinical Rotation.
Student: Must complete and sign Exhibit B-Student
Agreement. Must have health insurance coverage
under an accident and sickness health insurance
plan.
USA/Faculty: Provide to Medical Group-list of
Students who will be in facility, dates and obtain
approval from Medical Group.
Students: Must complete Exhibit A-Student
Agreement. Must carry health insurance coverage
during clinicals at Medical Group.
USA/Faculty: Obtain from each facility, acceptance
and acknowledgment of the students participation in
the clinical experience. Provide student information
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
(name and dates of clinical, health status,
immunization record, verification that student meets
the University's health requirements, evidence of
students health insurance coverage) to Medical
Group.
Ofc.)
Inspira Health Network, Inc. (to
include Inspira Medical CenterElmer and Inspira Medical CenterVineland)
Woodbury, NJ
IPC -InPatient Consultants of
Missouri, Inc. (Preceptor Agreement
Only-Must have correlating
agreement with facility)
St. Louis, Missouri
Nursing
RN-BSN, MSN, DNP
*Must accompany an agreement
with Facility*
Student: Must obtain and maintain health insurance
coverage. Must complete and sign Exhibit B-Student
Agreement.
USA Faculty and Students please read the
Conditions of Participation/NIAHO at the following
website: https://www.cms.gov/Regulations-andGuidance/Legislation/CFCsAndCoPs/Hospitals.html.
This listing is an agreement for the preceptor
employed by IPC, an affiliation agreement must also
be obtained for the facility (please check the
affiliation list; if agency is not listed please see
process to establish).
USA/Faculty: Provide to IPC a list of the students
who will be in clinicals, desired dates, and obtain
IPC's approval. Advise students in writing that their
participation in the clinical experience is conditioned
on adherence to: All instructions given by preceptor,
all rules and policies set forth by IPC and any facility.
Maintain confidentiality nature of patient - identifying
information that is disclosed to any student during
clinical.
Student: Must complete Exhibit B-return to agency.
Must carry health insurance.
J
Jack C. Montgomery VAMC
Muskogee, Oklahoma
Jackson Hospital
Marianna, Florida
Jackson-Madison County General
Hospital,
West TN Healthcare
Jackson, Tennessee
James A. Haley Veteran’s Hospital
Tampa, Florida
Jewish Hospital & St. Mary’s
Healthcare, Inc. d/b/a Jewish
Hospital
Louisville, Kentucky
Johns Hopkins Bayview Medical
Center
BSN, MSN, DNP
BSN, RN-BSN,
MSN, DNP
MSN, DNP
Agency only accommodating DNP, and CNL,
Nursing Education, Administration and
Informatics at this time. 5/5/2014
Exhibits A & B must be completed prior to beginning
clinical rotation. In addition, School must verify
negative status of Kentucky Board of Nursing Abuse
Registry check prior to commencement of the clinical
experience.
MSN
DNP
NNP
USA Faculty must submit Exhibit A&B(NNP ONLY)
Schedule A (MSN and DNP) (sites, placement dates,
and number of students) to agency, along with
DNP, CNL
41
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Baltimore, Maryland
Johns Hopkins Hospital -Downtown
Campus
Baltimore, Maryland
MSN, DNP
program curriculum and clinical education goals.
Students shall have completed blood borne
pathogen safety training under current regulations of
OSHA. Students must submit to: Johns Hopkins
Bayview Medical Center
Dept. of Nursing, Practice, Education & Research
4940 Eastern Avenue
Baltimore, MD 21224
Attn.: Elaine Sparks, MS, RN, NEA-BC
Professional Development Specialist
Phone: 410.550.0179
Fax: 410.550.4254
Email: esparksl@jhmi.edu
. Students must have health insurance coverage.
USA Faculty must possess a current, valid license or
certificate in area of professional specialty.
Agency contact: Laura Smith, Nursing Student
Placements. The Johns Hopkins Hospital,410-5835257, lgeshay1@jhmi.edu.
USA/Faculty: Complete Exhibit A-Placement
Information. At least 3 weeks prior to clinical.
Complete Exhibit 1. See Schedule 1 for Student
Information Required.
Students: Must provide background check results
submitted to Joseph Phelps, HR Investigator, The
Johns Hopkins Health System Corporation, 1101 E.
33rd Street, Baltimore, MD 21218, 443-997-7366,
jphelp11@jhmi.edu.
K
Kadlec Regional Medical Center
Richland, Washington
Kaiser Foundation Hospitals and the
Permanente Medical Group, Inc.,
California
RN, RN-BSN, MSN,
DNP
NP
USA Faculty: Complete the Student Audit form and
return to Ms. Heather Newell with a copy to USA
Clinical Affairs. Heather.Newell@kadlecmed.org,
509-942-2356.
That all students will have met health and
immunization requirements of Agency based on
state and local CDC requirements,
Contact Information:
Toni Groth-toni.groth@kp.org
Cheryl Kenner-cheryl.a.kenner@kp.org (Roseville
site only)
HOSPITALS
Jackie Lewis-jacqueline.m.lewis@kp.org
Hayward, San Rafael, Oakland, Santa Clara,
Redwood City, Santa Rosa, Richmond, South
Sacramento, Roseville, South San Francisco,
Sacramento, Vallejo, San Francisco, Walnut
Creek, San Jose
MEDICAL OFFICES
Antioch, Mountain View, Davis, Petaluma,
Fairfield, Pleasanton, Fremont, Rancho Cordova,
42
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Fresno, Richmond, Gilroy, Roseville, Martinez,
San Jose, Novato, Stockton, Napa, Vacaville,
Milpitas
Kaiser Foundation Hospitals/Kaiser
Foundation Northwest
Clackamas, Oregon
RN-BSN, MSN,
DNP
USA/Faculty: See Attachment B
Student: Complete C.
(Renewal request sent, set to expire
8/31/2016)
Keesler Medical Center, 81st Medical
Group,
Keesler AFB, Mississippi
Kenner Army Health Clinic (includes
MSN
All students must check in with Major Garrett Miller
(garrett.miller@us.af.mil). He will assist with all
clinical rotations at Keesler.
MSN, DNP
Wilkerson Pediatric Clinic)
Fort Lee, Virginia
Kettering Health Network
Dayton, Ohio
King’s Daughters’ Health
Madison, Indiana
MSN, DNP
Kinston Community Health Center,
Inc.
MSN, DNP
USA/Faculty: Provide written request to assign
students to facility, to include student names and
dates 30 days prior to clinicals. Please see Exhibit A
for Agency's health and immunization requirements
per the Ohio Dept. of Health. Sign Exhibit C.
Students: Provide proof of health insurance to
facility. Must sign Exhibit B - Student Orientation
Form.
USA Faculty must provide the number of students,
proposed schedule planned, and academic status of
each student participating in clinicals to the agency
(phillipsl@kdhmadison.org). Students are
responsible to meet Hospital health and safety
screening requirements set forth in Exhibit A (which
includes OSHA & HFAP Compliance certification)
and Hospital Non-associate Orientation Manual prior
to beginning clinicals.
(renewal request sent, set to expire
8/13/2016)
Kinston, North Carolina
Knox Community Hospital
Mount Vernon, Ohio
MSN, DNP
USA/Faculty: Must utilize the Student Clinical
Process (Part I). Notify at least one semester prior to
the beginning of clinical with verification of all
information contained on Part II Clinical Form.
Provide OSHA education on Protection from Blood
Borne Pathogens to students. Provide HIPAA
training. Please note Preceptor Compliance with the
Ohio Board of Nursing attached.
Student: Provide information to facility within Part III
Clinical Instructor Student Form.
Kootenai Health
Coeur d’Alene, Idaho
BSN, RN-BSN,
MSN, DNP
43
USA Faculty: Notify agency (Jessica MendozaJMendoza@kh.org) of name, title and contact of
USA Faculty per student, per clinical. USA, upon
agency request will provide a statement of its
policies on illness and injury, time loss for special
events, attendance requirements, and any other
policy applicable to student performance during
clinicals.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Students: Criminal background check within the past
3 years. Must have Idaho Health and Welfare
fingerprinting. Should acquire comprehensive health
and accident insurance throughout clinicals.
L
Lafayette General Medical Center
(agreement covers facilities that fall under
Lafayette Health Ventures, Inc., (covers
Lafayette General Southwest-contact
Monica Guidry-moguidry@lgh.org)
BSN, RN-BSN, MSN,
DNP
Students, please inquire with facility if the
facility/clinic would fall under Lafayette Health
Ventures, Inc.-If so, the USA paperwork will need to
indicate as such.
NP student will need to contact Amy Boudreauxapboudreaux@lgh.org—at least 3 weeks before
expected start date.
Lafayette, Louisiana
Copy of CV to include contact information, Copy of
any certifications: ACLS, BLS, etc., copy of TB test
result, Copy of License, copy of current malpractice
insurance, exact dates the student will be at facility
and the physician that they will be with. They will
also need to attend the hospital’s orientation that is
only offered twice a month. Monica Guidry (2897130) moguidry@lgh.org will contact student to set
that up at facility.
Lakeland Medical Center
New Orleans, Louisiana
Lakeview Regional Medical Center
Covington, Louisiana
MSN, DNP
MSN and DNP
Lakewood Regional Medical Center
Lakewood, California
MSN, DNP
Lallie Kemp Regional Medical
Center
Independence, Louisiana
Landstuhl Regional Medical Center
APO AE
Laurel Oaks Behavioral Health
Center
Dothan, Alabama
Lee Memorial Health System
(covers: LMHS Psychiatric
Consultation, Gulf Coast Medical
RN-BSN, MSN, DNP
MSN, DNP
USA/Faculty: Must complete Exhibits C & D
Attestations.
Student: Must complete Exhibits A & B. Must pass a
medical examination acceptable to Hospital prior to
clinicals, at least once a year.
USA Faculty: Coordinate assignments and rotation
plans with facility. Participate with the students in
Hospital's Quality Assurance and related programs.
Student: Must complete Exhibits A & B. Must view
videotape regarding Hospital's patient information
policies and practices provided by Hospital and
achieve a passing score at end of video. Must obtain
health insurance coverage.
Education Contact:
Robert L. Dennis, Jr.
Robert.l.dennis2.mil@mail.mil
RN, RN-BSN, MSN,
DNP
BSN, RN-BSN, MSN,
DNP
44
USA/Faculty and Student: Complete Exhibit BStudent Attestation.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Center, Health Park Medical Center,
Cape Coral Medical Center, and Lee
Memorial Hospital)
Cape Coral, Florida
Legacy Health
Portland, Oregon
BSN, RN-BSN, MSN,
DNP
USA/Faculty: Please see exhibit B for required
standards of clinical experience. Contact agency for
student assignments no later than one month prior to
start of clinicals. Contact-Amy Doepken-503-4133857-adoepken@lhs.org.
Student: Students must hold a current unrestricted
Oregon or Washington RN license. Must have
completed education in OSHA recommended safety
guidelines (including fire & electrical safety, personal
protective equipment, hazard communications, and
infection prevention practices). Must also have had
blood-borne pathogen training in accordance with
OSHA guidelines.
Leonard J. Chabert Medical Center
Houma, Louisiana
NP
LewisGale Montgomery
Blacksburg, Virginia
MSN, DNP
Student: Complete Exhibit A. Must receive
orientation packet from facility regarding patient
information privacy policies and practices.
USA/Faculty: Agency Contact: Renee St. Germain
via e-mail at Renee.StGermain@ochsner.org or by
phone at (985) 873-1819 Please contact Ms. St.
Germain for all clinical rotations and observations at
least 6 weeks prior to start date.
USA/Faculty: Complete Exhibit C and Addendum A.
Students: Must complete Exhibits A & B. Complete
the Attestation for Employee Health and Other
Student Compliance Requirements.
Life Net Psychiatry
Mandeville, Louisiana
LewisGale Medical Center
Graduate
Faculty and Students please read Requirements
Checklist and flu forms (if applicable), available from
the USA Contracts Office.
USA/Faculty: Please visit the following website for all
requirements after reading the checklist-
(Renewal request sent, set to expire
7/7/2016)
Salem, Virginia
http://www.lewisgale.com/careers/facultyrequired-reading.dot
Student: Please visit the following website for all
requirements after reading the checklist-
http://www.lewisgale.com/careers/studentchecklist.dot
LewisGale Physicians, LLC
Salem, Virginia
Graduate
USA/Faculty: Complete Exhibit C-Attestation Form
Student: Complete Exhibits A & B. Must pass
medical examination acceptable to facility prior to
clinicals at least once a year.
Faculty must be licensed, registered or certified
by the state of South Carolina.
Faculty: Submit a final written roster of names of the
participating students one week prior to the
beginning of the rotation.
Lexington County Health Services
District
West Columbia, South Carolina
Criminal background check must be
done within 90 days of student’s first
rotation at facility.
Lima Memorial Health System
MSN, DNP
(renewal request sent, set to expire
45
Please read, student list of requirements
Agency requires student & faculty names and
schedule of clinicals 3 weeks prior to beginning.
Students must contact Terri Metzger to sign LON -
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
tmetzger@limamemorial.org (as of 10/11/2013)
6/30/2016)
Lima, Ohio
Linden Oaks Hospital
Naperville, Illinois
Lovelace Health System
Albuquerque, New Mexico
RN-BSN, MSN, DNP
Student must maintain comprehensive health
insurance during clinical experience.
BSN, RN-BSN, MSN,
DNP
Students must have Drug and Background screening
(Exhibit B) completed and verified by Mary Meyer
The student must complete and sign Exhibit C
(Statement of Responsibility).
USA faculty must provide a roster of the names of
the Clinical Instructors and Students, along with the
rotation schedule. Any USA Instructors that will be
on-site are required to have a New Mexico license.
Licenses of the Instructors must be provided to the
System Coordinator prior to the beginning of
clinicals.
USA must provide verification of immunizations and
tests at least three days in advance of arrival at
Facility.
Students are not permitted to undertake any clinical
patient activity without supervision of Instructor,
never permitted to perform (i) double-check on
medications or blood products; or (ii) begin or
discontinue blood products, chemotherapy, or
experimental drugs and therapies. Students are
never permitted to accept orders from physicians or
other health care professionals in person or by
telephone, or call a physician or physician's office to
obtain an order.
Louisiana Heart Hospital
Lacombe, Louisiana
Lutheran Hospital of Indiana
Fort Wayne, Indiana
MSN, DNP
MSN, DNP
USA/Faculty: Please review addenda 1-3.
Students: Must have negative TB skin test within the
past year or, in the event of a positive TB skin test, a
chest x-ray within the past 3 years; or provide
evidence of no TB disease per negative result of
interferon-gamma release assay blood test (T-Spot
or Quantiferon Gold) within 12 months of student
clinicals at facility. Must complete and sign addenda
4 & 5 submit completed forms to agency.
Lyster U.S. Army Health Clinic
Fort Rucker, Alabama
MSN, ADVANCED
FAMILY NP
Training for an MSN degree and Advanced Family
NP. USA must notify agency 30 days prior to
clinicals: names, dates and hours of requested
students. Cathy Cole-Matson
cathy.l.cole-matson.civ@mail.mil
MSN, DNP
All instructors and students coming into the hospital
between October 1 and March 31 must have either
documentation of having received the influenza
vaccine or documentation of flu vaccine declination
prior to being scheduled in any department.
M
Manatee Healthcare System and
Lakewood Ranch Medical Center
Bradenton, Florida
46
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Marengo Family Health Center
Demopolis, Alabama
Marshall Medical Centers
Guntersville, Alabama
Martin Army Community Hospital
Fort Benning, Georgia
Martin Memorial Health Systems,
Inc.
Stuart, Florida
Mary Black Hospital
MSN, DNP
BSN, GRADUATE
BSN and graduate students
MSN, DNP
NP’s ONLY
Student: Must complete Addenda 1 & 2. Facility will
conduct and Student to pay for the background
check and substance abuse testing. Must have
health insurance during clinical experience at
Facility.
Mary Hitchcock Memorial Hospital,
Dartmouth-Hitchcock Clinic
Lebanon, New Hampshire
NP
Maury Regional Hospital d/b/a
Maury Regional Medical Center
Columbia, Tennessee
Mayo Clinic Jacksonville
Jacksonville, Florida
BSN, RN-BSN, MSN,
DNP
Nurse Practitioner Agreement – student must hold
an RN license to practice in the State of New
Hampshire. On-site Faculty must have an APRN NH
license.
USA/Faculty: Discussions between faculty and
preceptor will occur prior to, at the end of, and biweekly throughout student’s experience. Must
provide to facility, a Rider Letter for each request for
a Student clinical placement, to include;
Specific clinical unit (s) requested, dates and times
of requested clinical, name and title of faculty
members responsible for facilitating the clinical,
number of anticipated student, type of nursing
program, copy of the course syllabus, expectations
of learning experience, and evaluation criteria at
least 30 days in advance of clinical.
Student: Provide evidence of personal health
insurance. Must provide a BLS expiration date of
each student at least 30 days prior to clinicals. Must
provide all immunization required documentation 30
days prior to clinicals.
USA/Faculty: Must complete Exhibit A.
Student: Must have BLSHC Provider CPR.
(Renewal request sent, set to expire
7/31/2016)
Spartanburg, South Carolina
MSN, DNP
MAYO CLINIC EMPLOYEES ONLY-See
UPDATED APRN Request Form
USA Faculty: Must notify Mayo School of Health
Sciences before coming on Mayo Clinic campus to
make necessary arrangements for access. Mayo
Clinic contact is:
Patricia O'Rourke Fenno, MSN, RN
Clinical Nurse Educator
Clinical Education Department
Phone: 904-953-0329
Email: fenno.patricia@mayo.edu
Students: All students accepted for rotation are
subject to facility's admission standards.
Should you have any questions, please do not
hesitate to contact me. Any costs for the admission
requirements are the responsibility of the student.
McAlester Regional Health Center
BSN, RN-BSN, MSN,
47
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
McAlester, Oklahoma
McLeod Medical Center-Dillon
Florence, South Carolina
DNP
Nurse Practitioner
Agency contact: Haley Hill, Student CoordinatorHuman Resources-777-2595HHill@mcleodhealth.org
USA/Faculty: No later than 2 weeks prior to
beginning of clinicals submit to agency a
comprehensive program of instruction for NP track.
Also, include clinical assignments, dates, hours,
number of students, assigned instructors and types
of experiences. Verification of all required
immunizations, tests including but not limited to: (i)
TB; (ii) Hepatitis B vaccination series (or waiver); and
any other test that is now or may in the future be
required by state or federal law or regulation.
Student: Criminal Background check within 90 days
of admission to Program. Facility may require a drug
screen prior to clinical experience.
McLeod Regional Medical Center
Darlington, South Carolina
BSN, RN-BSN, MSN,
DNP
USA/Faculty: Must submit programs of instruction to
facility no later than two weeks prior to beginning of
each semester. Advanced notice of clinical
assignments, inlcuding dates, hours, number of
students, assigned instructors, and type of
experience. Keep facility informed as to needs of the
Program in order to c omply with the standards
outlined in Essentials of an Accredited Education
Program as publised by the applicable accrediting
organization. USA shall be responsible for
compliance with the regulations, with information and
training about the hazards associated with blood and
other potentially infectious materials, along with
information and training about the protective
measures to minimize the risk of exposure to blood
and other potentially infectious materials. Information
as to the reasons students should participate in
Hepatitis B vaccination. If any conflict arises USA
shall intervene within seven calendar days in an
attempt to resolve.
Student: Must have background check completed
within 90 days of admission to the Program. Facility
may require a drug screen prior to participation in the
Program.
Meadows Regional Medical Center
Vidalia, Georgia
MSN, DNP
Medical Center Enterprise
Enterprise, Alabama
48
USA/Faculty: Provide specific written clinical
behavioral objectives to preceptor prior to clinicals.
Submit a schedule with names of students and their
health records at least two weeks prior to clinicals
(Diana Sowell-912-535-5878dsowell@meadowsregaional.org.
USA/Faculty: Please see Addendum 1 regarding
Patient Care Services. Educate Students about
clinical safety, OSHA blood-borne pathogens
standards, and tuberculosis prior to clinicals. Obtain
written documentation from Students of 1. Negative
TB skin test within the past year or if positive TB skin
test, chest x-ray within the past three years; a
completed series of Hepatitis B vaccine, having
begun the series, or informed refusal of the vaccine;
and any other appropriate immunizations requested
by Facility. See Addendum 3. Require Students to
adhere to the Substance Policy, see Addendum
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
4.See Addendum 5 regarding Background Consent
Form.
Medical Center of Central Georgia
Macon, Georgia
Medical Center of Southeastern
Oklahoma
Durant, OK
Medical University Hospital Authority
Medical University of South Carolina
RN-BSN, MSN, DNP
NP
(Renewal request sent, set to expire
7/31/2016)
Charleston, South Carolina
Medicorp Health System (includes
Students: Complete Addendum 4 & 5.
USA Faculty and Students: Please see the 2015
updated instructions and attachments for
requirements per the agreement.
USA/Faculty: See Addendum 1 & 2 for Patient Care
Duties
Student: Completed addenda 4 & 5. Must have
health insurance during their clinical rotation at
Facility.
Code of Conduct and Communicable Disease
Attestation on file.
Contact: Teresa Guyton 843-792-0623.
USA Faculty: Complete the Documentation of
Compliance.
Mary Washington Healthcare)
Fredericksburg, Virginia
USA Faculty and Student POI:
Lila Pugh, Staffing Specialist, Human Resources,
lila.pugh@mwhc.com, (540) 741-1694
Franklin Square Hospital Center (a
Med Star Entity)
Rosedale, Maryland
Faculty and Student: Must provide curriculum to
Agency. Read and Complete Exhibits B-D (to
include health screening requirements),
Attachment B (Certificate of Student
Requirements must be provided to agency within
30 days prior to beginning clinicals . Criminal
background check and Drug Test must be done
within twelve (12) months prior to start of
clinicals. Students must maintain adequate
health insurance. Faculty will provide agency
with the names of students forty-fine (45) days
prior to their arrival.
USA/Faculty: Submit annual report (if students within
your specialty utilized this agreement) to indicates
the extent to which the objectives of the course have
been obtained.
Memorial Health Care System, Inc.
Chattanooga, TN
MSN, DNP
Memorial Health System ( to include:
Memorial Medical Center, the Abraham
Lincoln Memorial Hospital, mental Health
Centers of Central Illinois, Memorial Home
Services, NFP, Memorial Home Services of
Central Illinois, Memorial Physician Services,
The Passavant Memorial Area Hospital
Association)
Springfield, Illinois
Memorial Healthcare Group,
Inc./dba Memorial Hospital
MSN, DNP
49
Student: Must have Attachment B (Supervising
Physician Agreement) completed. Complete
Attachment C and D. Must have an annual TB
screening, including chest x-ray if applicable. Must
have OSHA approved training and education prior to
clinical experience.
USA/Faculty: Must provide evidence that student has
met the following requirements: CPR certification
and proof of immunizations for Hepatitis B
(vaccination), Measles, Mumps, and Rubella
vaccination; TB testing; and Varicella vaccine or
history of Varicella.
Student: Complete Facility's annual safety
community based learning (CBLs), including, but not
limited to, OSHA Compliance for Prevention of
Transmission of Bloodborne Pathogens and
Tuberculosis.
USA/Faculty: Must complete Exhibits C-D.
Students: Must complete Exhibits A-B.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Jacksonville, Florida
Drug and Alcohol Testing
Please note: To ensure the accuracy and fairness
of the testing program, all collection and testing
will be conducted pursuant to guidelines
established by the Medical Review Officers of
the testing facility and, if applicable, in
accordance with Substance Abuse and Mental
Health Services Administration (SAMHSA)
guidelines; a confirmatory test; the opportunity for
a split sample; review by an MRO, including
the opportunity for employees or students who
test positive to provide a legitimate medical
explanation, such as a physician's prescription, for
the positive result; and a documented chain of
custody.
MSN and DNP Students
Memorial Hermann Medical Group
Houston, Texas
MSN, DNP
Memorial Hermann Northwest
Hospital
Houston, Texas
MSN, DNP
Memorial Hermann Southwest
Houston, Texas
Memorial Hermann The Woodlands
Hospital
The Woodlands, Texas
MSN, DNP
MSN, DNP
Students must complete Exhibit B prior to beginning
clinicals.
Memorial Hospital at Gulfport
Gulfport, Mississippi
BSN, RN-BSN, MSN,
DNP
(Indoor and Outdoor) Tobacco free environment
Fingerprinting is required. Student pays $50 fee to
hospital.
Memorial Hospital University
Medical Center
Savannah, Georgia
Mercy Clinic Communities, Inc.
Oklahoma City, Oklahoma
USA/Faculty: Please contact Dr. Elliselizabeth.ellis2@memorialhermann.org and
VanessaJagassarvanessa.jagassar@memorialhermann.org for
student placement.
MSN, DNP
NP
50
Students: Must complete Exhibit B-HIPAA Form.
Students must complete Exhibit B prior to beginning
clinicals.
Because students may come into contact with
patients who have tuberculosis (TB), the University
of South Alabama College of Nursing accepts
responsibility for: (1) health screening of all
students,; (2) training of all students with regard to
hazards of TB; and (3) respirator fit testing of all
students assigned to Memorial Hospital at Gulfport
Faculty please complete Exhibit B (Faculty
Agreement) and Exhibit G (Verification of Student
Information) Student must complete attachments C
through F.
USA/Faculty: Prior to beginning of clinicals the
following information must be provided to the
agency, student name, schedules and activities to be
carried out in the clinical area, theory and clinical
objectives, faculty's name, address, office and cell
numbers, information on physical and educational
requirements per agency policy.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Nursing
Mercy Health Partners-Lourdes
Paducah, Kentucky
Mercy Health Cincinnati LLC
Cincinnati, Ohio
Mercy Health System of Northwest
Arkansas
Rogers, Arkansas
Student: Must attend orientation provided by agency.
USA/Faculty: Provide to Agency student liaison with
a list of students at least one week prior to the
clinical experience. Provide students with fire safety,
blood borne pathogens, and universal precautions in
compliance with OSHA. Note: The Agency has a
CRP (Corporate Responsibility Program) that
promotes prevention, detection and resolution of
instances of misconduct. USA shall immediately
notify Agency’s Corporate Responsibility Officer of
any violation of any applicable law or regulation of
USA students or faculty become aware.
Student: Complete Attachment A, see A-1, and see
the policies and procedures at
http://www.usccb.org/bishops/directives.shtml. Must
have physical examination showing they are free of
communicable diseases, to include TB tests and
required vaccinations. Must complete the Agency’s
in-service on HIPAA which will be part of the
student’s orientation process.
Students must read and sign Attachment A
(Administrative Confidentiality Policy).
USA/Faculty: Provide upon request names, health
status reports, and other pertinent information of
each student to be assigned to clinicals. Provide
training for Students in the HIPPA Regulations in
the OSHA Blood-Borne- Pathogens regulations.
Hazard Communication. Fire and Tornado and
Emergency Preparedness. School and Facility shall
arrange and provide orientation of Students
concerning the Facility's policies, rules, and
regulations. Agency contact: Nancy King, Executive
Director of Inpatient Services 479-338-2380
nancy.king@mercy.net.
MSN
Students: Should obtain and maintain health
insurance. Must provide documentation of criminal
background check.
Mercy Health System
Janesville, Wisconsin
RN-BSN, MSN, DNP
USA/Faculty: Notify Stephanie Walton, Education
Coordinator swalton@mhsjvl.org prior to student’s
clinicals. Provide copy of performance objectives for
clinicals. Provide documentation of students training
in blood and body fluid universal precautions to
agency.
Students: Must complete exhibits A & B. Must have
received training in blood and body fluid universal
precautions consistent with US Centers for Disease
Control. Must be vaccinated for influenza by
November 15th.
Faculty must send following information to agency
prior to beginning of clinicals: Student name,
Schedules and activities to be carried out in the
clinical area throughout the experience, theory and
clinical objectives, faculty's name and contact
information. Agency contact: Melinda Sharummelinda.sharum@mercy.net
Mercy Hospital-Ardmore
Ardmore, Oklahoma
NP
Mercy Hospital Fort Smith
Fort Smith, Arkansas
BSN, RN-BSN, MSN,
DNP
51
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Mercy Hospital Joplin
Joplin, Missouri
Mercy Medical Center
Des Moines, Iowa
Mercy Hospital Oklahoma City, Inc.
Oklahoma City, OK
BSN, RN-BSS, MSN,
DNP
MSN, DNP
Exhibit A must be completed and signed by student.
NP
USA/Faculty: Shall provide student names,
schedules, activities to be carried out in the clinical
area, theory and clinical objectives, faculty member's
name, address, contact information. Facility will be
responsible providing orientation to students as to
rules and regulations of facility.
Students: Must complete orientation from facility.
Mercy St. Vincent Medical Center
Toledo, Ohio
Merit Health Woman’s Hospital
Flowood, MS
Exhibit A must be completed prior to beginning
clinicals.
Nursing
Meriter-Unity Point Health
Madison, Wisconsin
Methodist Health System (to
include: Methodist Dallas Medical
Center, Methodist Charlton Medical
Center, Methodist Mansfield Medical
Center, and Methodist Richardson
Medical Center
Richardson, Texas
MSN, DNP
Student: Must complete Addenda 4, 5, and 7. Must
have a negative TB skin test within the past year or,
in the event of a positive TB skin test, a chest x-ray
within the past three (3) years; OR provide evidence
of no TB disease per negative result of interferongamma release assay blood test (T-Spot or
Quantiferon Gold) within twelve (12) months of
student activity at facility ; (b) a completed series of
Hepatitis-B vaccine, having begun the series, or
informed refusal of the vaccine; and (c) any other
appropriate immunizations requested by Facility.
Must have health insurance.
Faculty and Students please see exhibit 1 for agency
requirements per the addendum.
USA Faculty must notify Meriter Hospital Medical
Affairs Health Services and the Family Psychiatric
Mental Health Practitioner in advance with
participating student names and affiliation dates.
Students must check in with Medical Affairs for a 10minute orientation on the first day, or prior to, the
start of clinical rotation. Student must provide
documentation of influenza vaccination. State of
Wisconsin requires evaluation of TB status annually.
Student must have Caregiver Background Check.
USA must certify in writing to agency that no student
has any offenses on the Offenses List (Appendix III
of the Wisconsin Caregiver Program Manual). USA
will provide Agency with a letter that includes each
Student’s name and ss# and listing any findings of
misconduct found during the Caregiver Background
Check.
Faculty please see Exhibits A&B. Students must sign
Exhibit C.
Students must sign Exhibit A (Hepatitis Statement)
prior to beginning clinicals. Students must show
documentation of flu vaccine. As of January 1,
Methodist LeBonheur Healthcare
(covers: University, Germantown,
52
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
North, South, Olive Branch, and Le
Bonheur Chidlren’s Hospital, and
many clinics)
Memphis, Tennessee
Midwest Regional Medical Center
Midwest City, Oklahoma
Minden Medical Center
Minden, Louisiana
Minden Physician Practices, LLC
d/b/a The Womens Clinic
Minden, Louisiana
2013-Students must have a background check
and 10-panel drug screen completed through
either Verified Credentials or Certified
Background. No other vendor will be accepted.
USA/Faculty and students: See Addenda 1-5 for
additional requirements.
MSN, DNP
MSN, DNP
Student must contact Allison Ouzts at 318-371-3266
to coordinate clinicals. Each student who will be or is
in facility from October 1st to April 1st to show proof
of Flu Vaccine. If the student is unable to take the
FLU vaccine due to medical reasons, Religious
beliefs, or chooses to decline they must sign a
declination and submit that record to the hospital.
All students who do not comply with the mandatory
flu vaccine must wear an N-95 duck bill mask at all
times and in all locations other than the cafeteria or
private offices while in Minden Medical Center.
Please have students sign an acknowledgement of
this fact if they decline the vaccination.
USA/Faculty: Provide recommended objectives of
the fieldwork experience and provide objectives to
facility. If requested USA Faculty shall make periodic
visits to the facility for the purpose of discussing the
clinical experience of the students. Provide student
information to facility at least one month in advance
to facility. Notify facility of any student absences.
Student: Obtain and maintain health insurance
coverage. Upon request of facility, student must sign
a confidentiality agreement.
Faculty Licensure Required RN & APRN. CNS
and Executive Nursing require RN Licensure.
Ministry Health Care, Inc.
Weston, Wisconsin
USA/Faculty: Submit a description of syllabus
requirements and other clinical objective
expectations to facility. Also, provide a letter
indicating the names, social security numbers of
student. Complete the Background Information
Disclosure Form (BID), available from agency.
Agency Education Manager, Brant Bergeron-715343-3371, brant.bergeron@ministryhealth.org.
Student must have health care worker safety
education according to OSHA standards.
Student: Must have a background check in
accordance with the Wisconsin Caregiver
Background Check Law.
Minneapolis VA Health Care System
Minneapolis, Minnesota
DNP
(Minnesota sites should only
be utilized by approved USA
students)
USA/Faculty: Send the student information to the
facility. (Facility contact: Jennifer Jacobson, Dean of
Health, jennifer.jacobson@minnesota.edu-218-299-
Minnesota State Community and
Technical College
53
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
6817).
Moorhead, Minnesota
(Minnesota sites should only
be utilized by approved USA
students)
Mission Hospital, Inc. and Carolina
Mountain Emergency Medicine, PA.
Asheville, North Carolina
Student: Must maintain health insurance coverage.
ONLY the following
programs are covered
DNP-Family Psych
MSN-CNS
Questions for onboarding and orientation processes:
Mission Education Services
828-213-0779
Education.Services@msj.org
USA/Faculty: Submit roster of students who will
participate in the clinical experience at Facility.
Students-May be required to participate in any
required orientation process developed by the
Facility.
Mississippi State Hospital
Whitfield, Mississippi
Mississippi State Department of
Health
Undergraduate and
Graduate Students
(Renewal request sent, set to expire
7/31/2016)
Jackson, Mississippi
MMA-Vista Family Health, Inc.
Asheville, North Carolina
MSN-FNP
Pediatric Primary
NP
Mobile County Health Department
Mobile, Alabama
Mobile County Public Schools
Mobile, Alabama
Mobile Infirmary Association d/b/a
BSN, RN-BSN, MSN,
DNP
Mobile Infirmary Medical Center
Faculty please make arrangements for clinical
locations and times with the county
coordinating nurse/and or the district chief
nurse. County health department contact
information can be found on the MSDH
website at http://msdh.ms.gov under the
location tab. District chief nurse list is on the
agency attachments list.
MSN-FNP ONLY
Agency Contact: Education Services 828-2130779
education.services@msj.org for any questions
regarding onboarding or orientation.
USA/Faculty: Provide at least 14 days prior to
commencement date of clinical experience,
roster of students, detailed clinical schedules
and descriptions of curriculum and appropriate
scope of program. Upon request, provide to
agency written outline or statements detailing,
the various academic or temporal components
of the clinical experience, objective of the
clinical experience from the standpoint of the
University, expectations of the University with
respect to behavior, conduct, and language of
students.
Student: Must hold valid certification in
professional-level CPR, as applicable.
Undergraduate and
Graduate Students
BSN, RN-BSN, MSN,
DNP
Mobile, Alabama
USA Faculty and Students-Please see the
Standards of Conduct.
As a reminder, please submit all required forms
at least 2 weeks prior to your clinical start date
and complete forms as required. Please refer to
the “Clinical Placement Guidelines for Nursing
Students” on the IH Nursing Student webpage at
http://www.infirmaryhealth.org/nursing-students
54
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
for detailed information. All but the IH Student
Information form may be submitted
electronically. Each form on the IH nursing
student webpage at
http://www.infirmaryhealth.org/nursing-students
has a facility selection field and a submit button
in the upper section of the form. Complete the
form as required, then select the facility where
the form needs to be submitted to, and finally
submit the form by clicking on the submit button.
You will receive a confirmation that the form has
been submitted.
Faculty must provide Kaitlyn Hunt (251-435-5233)
with a schedule, name of clinical instructor, and
clinical instructor for each group of students
indicating days of the week, hours of clinical
experience, number of students, type of clinical
experience, first and last date of rotation. The
agency did not provide a specific form. Students
must complete a 45 minute Healthstream module
for orientation. Once the module has been
completed by student the Letter of Notification
will be returned along with the student badge
and parking decal.
Mobile Ob-Gyn, P.C.
Mobile, Alabama
Moncrief Army Community Hospital
Fort Jackson, SC
BSN, RN-BSN, MSN,
DNP
MonteVista Hospital
Las Vegas, Nevada
Moses H. Cone Memorial Hospital
d/b/a Cone Health
Greensboro, North Carolina
RN-BSN, MSN, DNP
FAMILY
PSYCHIATRIC NP
Family Psychiatric Nurse Practitioner students.
Students must complete Student Packet (in
attachments folder). Once completed students must
contact the Hospital Education Department 803-7512488.
Please note: All Students or faculty who have
traveled to one of the West African countries
(Liberia, Sierra Leone, or Guinea) should refrain
from attending clinical experiences at Cone
Health within 21 days of their return to the US.
Any students or faculty who are ill (fever, sore
throat, cough, runny nose, etc.) should not report
to any clinical site or should not return to Cone
Health clinical areas until they have been afebrile
for at least 24 hours without the use of
antipyretics.
A negative Twelve Panel Urine Drug Screen report
test from a National Institute of Drug Abuse (NIDA)
approved laboratory on file prior to the first
assignment/student experience at MCHS with USA
CON.
Mountain States Neonatology, Inc.
Phoenix, AZ
NNP
ONLY TO BE UTILIZED IN CONJUNCTION
WITH SAIN ALPHONSUS MEDCIAL
CENTER
USA/Faculty: Notify Agency through preceptor
of the planned schedule of each student’s
assignment, including name, level of clinical
training, length and dates of clinical
experience.
55
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
MountainView Hospital
Las Vegas, Nevada
Munroe Regional Medical Center
Ocala, Florida
MSN, DNP
BSN, MSN, DNP
USA/Faculty: Must complete Exhibit C-Attestation
Student: Must complete Exhibits A-B. Must pass a
physicial examination at least once a year.
USA/Faculty: Must provide student name, residence
address, phone number to agency at least ten days
prior to placement at facility. Prior to commencing
performance per the agreement, the COLLEGE shall
ensure health status of student and faculty entering
premises is compliant with the following
requirements of the AGENCY and shall produce
documentation upon request:
Statement by a healthcare provider that student is
medically capable of performing internship related
duties and is free of any communicable diseases.
Documentation of a negative ppd within the last year
(two – step ppd if more than one year) or Chest XRay if past positive ppd. Documentation of active or
passive immunity to Measles, Mumps, Rubella,
Rubeola, Diphtheria, Pertussis, Tetanus, Hepatitis B
and Varicella.
Student must contact Workforce Development
Coordinator with Munroe to complete orientation
packet prior to beginning clinicals.
N
Natchitoches Regional Medical
Center
Natchitoches, Louisiana
Nathan Adelson Hospice
Las Vegas, Nevada
BSN, RN-BSN, MSN,
DNP
National Jewish Health
Denver, Colorado
Navajo Area Indian Health Service
BSN, RN-BSN, MSN,
DNP
See Exhibit A-Immunization requirements per the
agreement.
RN-BSN, MSN, DNP
Student: Complete Exhibit A. Must pass a criminal
history background check, pursuant to the Indian
Child Protection and Family Violence Prevention Act,
to include fingerprint check.
USA must submit to agency 3 weeks prior to
the beginning of clinical rotation, a schedule
indicating number and names of students
participating and the name of their supervising
faculty.
(to include: Gallup Indian Medical Center,
Tohatchi Health Center, Northern Navajo Medical
Center, Four Corners Regional Health Center,
Crownpoint Health Care Facility, Thoreau Health
Clinic, Pueblo Pintado health Center, Chinle
Comprehensive Healthcare,Tsaile Health, Pinon
Health, Kayenta health Center, Inscription House
Health Center)
Arizona and New Mexico
Naval Health Clinic New England
Naval Branch Health Clinic Groton
Groton, Connecticut
Naval Health Clinic Cherry Point
Marine Corp Air Station
MSN, DNP
Nurse Practitioner
56
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Cherry Point, North Carolina
Naval Health Clinic-Goose Creek
Charleston, South Carolina
Naval Health Clinic Quantico
NP
Student must complete Trainee Agreement.
Graduate
(Renewal request sent, set to expire
7/1/2016)
Quantico, VA
Naval Hospital (to include Its Branch
Clinics, i.e., Whiting Field Clinic)
Pensacola, Florida
Naval Hospital, Camp Lejeune
Camp Lejeune, North Carolina
Naval Medical Center
Portsmouth, Virginia
NCH Healthcare (Naples
Community Hospital)
RN-BSN, MSN, DNP
RN-BSN, MSN, DNP
GRADUATE, NP
NP
(Renewal request sent, set to expire
7/31/2016)
Graduate and NP Students—See faculty first
***Faculty must contact the agency and complete
the agency’s request form prior to students
starting clinicals. Students please see agency
official regarding Parking regulations. Students
must complete Trainee Agreement.
Student must have completed and provided to
agency the Virginia Criminal Information Network
(VCIN) Investigation and the SF86 (Questionnaire
for Public Trust Positions) which includes FBI
fingerprint check and financial check (submitted
by NMCP/conducted by OPM).
USA Faculty: Shall confirm in writing that each
student has on file a record of completed
immunizations and CPR as appropriate. Shall
provide Agency with current curriculum.
Student: An administrative fee of $150.00 per
student, payable to NCH Healthcare System, Inc.,
will be charged and is due from the student two
weeks prior to the start of clinical placement. The
fee should be sent to the attention of Carol
Johnson, Department of Education, NCH
Healthcare System.
Naples, Florida
Nebraska Methodist Hospital
Omaha, Nebraska
Nemours Foundation (includes
Contract includes: Allied Health students
Students are required to complete a confidentiality
statement prior to clinical experience (See faculty)
MSN, DNP
USA/Faculty: Please see required attachments in
Pub Docs.
Children’s Clinic in Destin, FL and the Alfred
I. DuPont Nemours in Wilmington, DE)
Pensacola, Florida
New Hanover Regional Medical
Center
One month prior to placement number of students
must be agreed upon between Facility and
University. Ten (10) days prior to clinicals USA
faculty shall provide the Director with the names of
the Students scheduled for clinicals along with the
name and number of Faculty members. Faculty will
need to provide proof of licensure and clinical
competency. Plan curriculum as guided by the NLN,
AACN, and the North Carolina Board of Nursing.
Students are responsible for the cost of any and all
equipment determined to be damaged because of
direct or indirect negligence or carelessness by the
student. Students must have annual Influenza
(renewal request sent, set to expire
8/1/2016)
Wilmington, North Carolina
57
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
vaccine if in facility during October through March.
USA must provide written assurance that a criminal
background check has been conducted. USA shall
provide Students with education regarding blood
borne pathogens appropriate to the student’s
educational training and maintain documentation of
such education.
Newberry County Memorial Hospital
Newberry, South Carolina
NIH Clinical Center
Bethesda, Maryland
North Baldwin Infirmary
Bay Minette, Alabama
North Fulton Women’s Specialists &
North Fulton Hospital
Roswell, Georgia
North Mississippi State Hospital
Tupelo, Mississippi
North Mississippi Medical CenterPontotoc
Pontotoc, MS
North Mississippi Medical CenterTupelo
Tupelo, Mississippi
Undergraduate and
Graduate Students
MSN, DNP
USA/Faculty: Communicate with the Clinical Center
Nursing Department (Diane Walsh, 301-326-7040dwalsh@cc.nih.gov.
Student must have personal medical/health
insurance coverage during clinical experience at
facility.
USA Faculty and Students-Please see the
Standards of Conduct.
FNP
Student must complete Exhibits A& B. Faculty to
complete Exhibit C.
Program must be approved by hospital prior to the
beginning of clinicals.
NP
Nurse Practitioner
Programs Only
Nursing and Nurse
Practitioner Programs
USA/Faculty: Annual joint meeting to evaluate the
Clinical Education Program.
Student: Require each student to submit proof and
be considered immune by providing the following: (1)
Documentation of having received two live measles
containing vaccinations after their first birthday, (2)
documentation of initial two step and up to date TB
skin test followed by annual testing, (3)
documentation of three Hepatitis-B vaccinations or in
process, (4) documentation of having received a
tetanus containing vaccination within the past 5
years and a prior tetanus/diphtheria/pertussis (5)
documentation of flu vaccine October-March or
alternatively require student to sign a waiver and
wear a mask when in a NMHS owned or operated
facility. Medical contraindications to vaccines and
positive TB skin test follow-up must be reviewed by
NMMC Pontotoc Employee Health. Complete Health
Sciences Advisory on Employment and Criminal
Offenses (Exhibit A) and Healthcare Criminal History
Background Affidavit (Exhibit B). Complete Student
Agreement. Obtain and maintain health insurance
during clinical experience.
USA/Faculty: Annual joint meeting to evaluate the
Clinical Education Program.
Student: Require each student to submit proof and
be considered immune by providing the following: (1)
Documentation of having received two live measles
containing vaccinations after their first birthday, (2)
documentation of initial two step and up to date TB
skin test followed by annual testing, (3)
documentation of three Hepatitis-B vaccinations or in
process, (4) documentation of having received a
tetanus containing vaccination within the past 5
years and a prior tetanus/diphtheria/pertussis (5)
58
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
documentation of flu vaccine October-March or
alternatively require student to sign a waiver and
wear a mask when in a NMHS owned or operated
facility. Medical contraindications to vaccines and
positive TB skin test follow-up must be reviewed by
NMMC Tupelo Employee Health. Complete Student
Clinical Agreement Exhibit A, Health Sciences
Advisory on Employment and Criminal Offenses
Exhibit B and Healthcare Criminal History
Background Affidavit.
Obtain and maintain health insurance during clinical
experience.
Students must notify agency education director
Nicole Barnum (985-230-6594) prior to starting
clinicals. Must be in compliance with Louisiana State
Board of Nursing. Only selected students may
participate that have completed prerequisite portion
of curriculum. USA CON must complete Exhibit 1
Pre-A
Assignment Results Form prior to student beginning
clinicals.
North Oaks Health System (includes
North Oaks Rehabilitation Hospital
Hammond, Louisiana
North Okaloosa Medical Center
Crestview, Florida
Northeast Alabama Regional
Medical Center
Anniston, Alabama
NP
BSN, RN-BSN,
MSN,DNP
All students will be required to provide proof of
Influenza vaccination on or before November 1,
2013. USA faculty must provide a roster of students
participating in clinicals and attach proof of influenza
vaccination. Students not in compliance with these
guidelines will not be able to participate in clinical
rotations after November 1st.
Students are required to participate in an hourly
rounding lab before clinicals at facility. NP
students only.
Prior to clinicals , each student shall be skin tested
for TB, with the initial 2-step test and proof of annual
TB testing, provide written evidence thereof to
Facility.
Student: Must complete facility’s orientation and
acknowledgment sheet through agency and return to
agency’s Human Resources prior to clinicals.
Northeast Human Service Center
Grand Forks, North Dakota
Northern Arizona Healthcare (to
include: Flagstaff Medical Center,
Verde Valley Medical Center, and
Northern Arizona Homecare)
Flagstaff, Arizona
Northport Medical Center (DCH
Hospital Authority)
Northport, Alabama
Northside Hospital
Atlanta, Georgia
Nursing
USA/Faculty: Provide students name, level of
academic preparation, length and dates of
experience.
Student: Must complete Student Waiver Form.
Students must check in with the education
department at the facility and complete the student
module prior to starting clinicals. Students may find
the module and paperwork on the facility’s website:
www.nahealth.com/education. Once completed they
can fax to 928-773-2430.
BSN, RN-BSN, MSN,
DNP
BSN, MSN, DNP
USA/Faculty: See Exhibit C.
At time of enrollment in the program: student
will need to have a physical exam (to include: PPD
test or chest x-ray, hepatitis -B core antibody test,
and Rubella and Measles test or documentation of
59
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
immunization). Student to complete Exhibit B.
Northwest Arkansas Hospitals, LLC
( to include; Northwest Medical
Center-Springdale, Northwest
Medical Center-Bentonville, Willow
Creek Women’s Hospital
Johnson, Arkansas
USA/Faculty: Must provide clinical coordinator
contact information to facility. Keep on file a copy of
the Student's completed addenda 4 & 5. This may be
sent to the USA Clinical Affairs Department.
Northwest Physicians, LLC-Benton
County Physician Services
Springdale, Arkansas
USA/Faculty: Must provide clinical coordinator
contact information to facility. Keep on file a copy of
the Student's completed addenda 4 & 5. This may be
sent to the USA Clinical Affairs Department.
Student: Must complete addenda 4 & 5. Must have
health insurance during their clinical experience at
Facility.
Student: Must complete addenda 4 & 5. Must have
health insurance during their clinical experience at
Facility.
Northwestern Memorial Hospital
Chicago, Illinois
RN-BSN, MSN, DNP
Student: Complete Exhibit A. Must provide proof of
full health insurance. Background Check must be in
compliance with the Illinois Healthcare Workers
Background Check Act.
Norton Healthcare/ Neonatal
Associates (Norton Kosair Children’s
NP
NP Students.
Faculty must schedule/coordinate clinical experience
with facility at least 6 weeks in advance of clinicals.
Hospital, Norton Suburban Hospital, Norton
Audubon Hospital, Norton Hospital, and
Norton Brownsboro Hospital)
Louisville, Kentucky
Norton Hospitals, Inc. (Norton Audubon
Student: Must have negative drug screen within six
months of placement at Hospital.
Hospital, Norton Brownsboro Hospital,
Norton Women’s & Kosair Children’s
Hospital, Kosair Children’s Medical CenterBrownsboro, and Kosair Children’s Hospital)
Lexington, Kentucky
O
Faculty and Students please see the (detailed)
Oakwood Corporate Nursing Policy and Procedures
for Clinical Placement.
USA/Faculty: Must provide names, date of birth,
address, phone number, emergency contact
information, demographic data, of students no later
than one week prior to clinicals.
Students must have umbrella coverage of general
liability insurance and provide verification of said
insurance to the University prior to clinicals. Student
must have health insurance.
Oakwood Healthcare, Inc.
(including, OHI, Oakwood, OH and
Medical Center-Dearborn, Oakwood
Heritage, Oakwood Annapolis,
Oakwood Southshore Medical
Center, and Ambulatory
Dearborn, Michigan
60
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
MSN, DNP
Ocala Health (Ocala Regional
Medical Center & West Marion
Community Hospital)
Ocala, Florida
Ocala Health Primary Care, LLC
d/b/a Family Care Specialist
Ocala, Florida
\
OCH Regional Medical Center
Starkville, Mississippi
Ogden Clinic
Ogden, Utah
OhioHealth Corporation (to include:
BSN, RN-BSN, MSN,
DNP
USA/Faculty: Provide adequate documentation
attesting to competency of each instructor. Complete
Exhibit C-Attestation.
Student: Complete Exhibit A and B. Must pass
medical examination acceptable to Hospital prior to
experience.
USA/Faculty: Must complete Exhibit C-Attestation
Statement and return to Agency Contact. Tracy
Pickover-352-629-7979tracy.pickover@hcahealthcare.com.
Student: Must complete Exhibits A & B.
BSN, RN-BSN, MSN,
DNP
Doctors Hospital, Dublin Methodist
Hospital, Grady Memorial Hospital,
Grant Medical Center, Marion General
Hospital, Riverside Methodist Hospital)
Columbus, Ohio
Ohio State University Medical
Center
Columbus, Ohio
Ohio State University- on behalf of
The Arthur James Cancer Hospital
and Richard J. Solove Research
Institute
Columbus, Ohio
Okaloosa County Health Dept.
Fort Walton Beach, Florida
Oklahoma City Area Indian Health
Service (covers, White Cloud Health Station,
Agency contact is Jolene Guarniere, HR Specialist &
Student Coordinator, Ogden Clinic (801) 475-3429
jolene.guarniere@ogdenclinic.com
USA/Faculty: Notify Facility at least seven (7) days
prior to clinicals and again the day the clinical
begins.
Terra Purdy
614-566-3374
Terra.Purdy@ohiohealth.com
Student: Must obtain health insurance coverage.
Students please request information about Ohio
Board of Nursing Requirements(Attachment A)
Faculty members please see me regarding
attachment A prior to student’s clinical experience
BSN, RN-BSN, MSN,
DNP
BSN, RN-BSN,
MSN, DNP
Haskell Indian Health Center, Claremore Indian
Hospital, Pawnee Indian Health Center, Wewoka
Indian Health Center, Clinton Indian Health
Center, El Reno Indian Health Center, Watonga
Indian Health Center, Lawton Indian Hospital,
Anadarko Indian Health Center, Carnegie Indian
Health Center)
Oklahoma City, Oklahoma
Oklahoma City Indian Clinic
Oklahoma City, Oklahoma
BSN, RN-BSN, MSN,
DNP
Oklahoma State Department of
Health
Oklahoma City, Oklahoma
61
Students must provide agency with a copy of their
current criminal record check and shot records to
include: proof of TB skin test (within 1 year), proof of
rubella/rubeola, proof of chickenpox (either
immunization, titer, or signed statement of past
infection), and proof of Hep B immunization or
declination form.
Students must complete HIPAA Training for Nursing
Students at https://ok.train.org/desktopshell.aspx.
Please see clinical faculty for detailed instructions.
Once the students complete the HIPAA online
training, they will be able to print out a certificate.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Prior to clinical experience, USA must provide
Student’s name, schedule and activities to be carried
out in the clinical, theory and objectives, faculty’s
name and contact information. Agreement covers
ALL county health departments.
Oneida Community Health Center
Oneida, Wisconsin
Orange Park Medical Center
Orange Park, Florida
BSN, RN-BSN, MSN,
DNP
RN-BSN, MSN, DNP
Only.
Students must complete and sign Exhibits A & B.
If requested by agency (depending on
responsibilities) students may have to provide a
copy of their consumer credit report to agency.
Exhibit C must be initialed and dated by Mary
Meyer.
USA Faculty: Must verify, complete, and sign the
Student Affiliation Checklist.
Agency Education Contact: Bonnie Cox
coxbo@ohsu.edu 503-494-3698.
Oregon Health & Science University
Portland Oregon
Students: Must provide proof of up-to-date
immunizations, CPR certification and
Bloodborne Pathogen training. Complete OHSU’s
HIPAA Privacy Training prior to beginning
Clinicas at OHSU. Provide OHSU with proof of
having successfully passed criminal background
screening and drug screening.
Student must complete Attachment A, “Affiliation
Confidentiality Agreement,” prior to beginning
clinicals.
Students must complete Attachment 1 (Student
Agreement), Attachment 2 (Confidentiality
Agreement), and Attachment 3 (Statement of
Responsibility) prior to beginning clinicals.
OU Physicians
Oklahoma City, Oklahoma
Our Lady of the Lake Ascension
Community Hospital, Inc. d/b/a St.
Elizabeth Hospital
Gonzales, Louisiana
Our Lady of the Lake Ascension
Community Hospital, Inc. d/b/a St.
Elizabeth Physicians
Gonzales, Louisiana
Our Lady of the Lake Assumption
Community Hospital, Inc.
Nepoleonville, Louisiana
Our Lady of the Lake Physician
Group, LLC
Baton Rouge, Louisiana
Our Lady of the Lake Regional
Medical Center
Baton Rouge, Louisiana
USA Faculty cannot do site visits to this facility.
Students must complete Attachment 1 (Student
Agreement), Attachment 2 (Confidentiality
Agreement), and Attachment 3 (Statement of
Responsibility) prior to beginning clinicals.
Students must complete and sign Attacments 1-3
Students must complete Attachments 1-3 prior to
beginning clinicals. USA Faculty please see
procedure checklist, request form, practitioner
letter, Orientation Packet. Facility needs to receive
a list of student’s names and rotation information
along with the OLOL Physician Group’s
requirements at least three weeks prior to the
agreed upon start date of the rotation, send this
information to Julia Sigur - julia.sigur@ololrmc.com
Please request all corresponding attachments from
the contracts office.
Prior to contacting agency, students must have a
background check, TB skin test, and a CURRENT
(within 1 semester) drug screen, and complete
Attachments 1-3. If using a non-OLOL employed
PNP, DNP
62
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
physician or third level, the Revised Sponsoring
Physician Letter must be signed prior to meeting
with Dr. Steele-Moses. Students/faculty should
contact Dr. Susan Steele-Moses, Program Director
for Nursing Research prior to beginning clinicals to
ensure compliance with all requirements. Agency
must receive electronic clinical objectives. Program
Director must receive specific dates student will be in
this facility. Agency will visually check RN licensure
and current CPR prior to student beginning at this
facility.
To include PNP program.
To include DNP program.
Our Lady of Lourdes Regional
Medical Center Lafayette, Louisiana
P
Palm Beach County Health
Department, Florida
West Palm Beach, Florida
Palm Beach Gardens Community
Hospital, Inc.
Palm Beach Gardens, Florida
Palmetto Medical Initiative
Charleston, South Carolina
Paragon Contracting Services, LLC
Gables, Florida
Nursing
BSN, RN-BSN, MSN,
DNP
MSN, DNP
Student must secure health insurance coverage at
own expense and carrier must be approved by
Hospital. Student must complete Exhibits A & B.
Faculty must complete Exhibit C (Attestation Form).
Students: Shall be responsible for Agency program
costs as outlined by Agency, from time to time, for
particular programs.
MUST HAVE AN AGREEMENT IN PLACE WITH
FACILITY WHERE THE PRECEPTOR IS
EMPLOYED BY PARAGON CONTRACTING
SERVICES, LLC.
LON Process: Letter of Notification and Appreciation
will be filled out a little differently. First, in the first
blank, the LON will say "... and thank Facility Name/
Paragon Contracting Services for providing..." Next,
the line titled "Preceptor Signature" will now read
"Preceptor Signature- Paragon Contracting
Services." Thus, the preceptor, as a Paragon
employee, will sign as the Paragon official. Lastly,
the Agency official will sign on the final, line which
reads "Appropriate Agency Official." In summary,
only one LON and Appreciation will be used for both
agencies instead of two.
Parkview Medical Center
MSN
63
USA/Faculty: Notify Paragon and responsible
preceptor of the planned schedule of each student
assignment, student name, level of academic
preparation, and length and dates of the clinical
experience.
MSN Students Only
USA/Faculty: Provide agency with a letter
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
addressing the following:
Specific dates and times during which the
educational experiences will be conducted;
Full legal names of each student assigned to the
educational experience;
Ratio of students participating in the educational
experience (if applicable);
Faculty name and contact information responsible for
making student assignments;
Proposed scope of student involvement in patient
care activities, if any;
Description of student learning objectives for each
education experience;
Orientation schedule for students participating in
educational experience;
Indication of qualifications for preceptors;
Copy of any material preceptors are required to sign
prior to participating in the educational experience.
Agency contact: Melissa Haro haro@parkviewmc.com-719-584-4000.
(renewal request sent, set to expire
6/30/2016)
Pueblo, Colorado
Student: Must be current in there licensure.
PeaceHealth-St. Joseph Medical
Center
Bellingham, Washington
MSN
MSN Students Only
Agreement for employees of facility only.
Student-Must obtain a national criminal background
check. Must complete a urine test for prohibited
substances. If completed at facility, student shall
reimburse facility for the costs of the test before their
clinical rotation may begin. Students must provide
Facility with the location where they received the
annual influenza immunization and the date thereof,
prior to beginning clinicals.
Pediatrix Emergent & Critical Care
Services, LLC
Richardson , Texas
Pediatrix Medical Group of
Louisiana, LLC (services Women’s
and Children’s Hospital)
Lafayette, Louisiana
Graduate
Pediatrix Medical Group of South
Carolina, PA and Palmetto Health
Columbia, South Carolina
NNP Students ONLY
Pediatrix Medical Services, Inc.
Richardson, Texas
BSN, RN-BSN, MSN,
DNP
NNP
NNP Students Only
USA/Faculty: Notify the Program Coordinator of the
planned schedule of the student's assignments,
including name of student and their level of training,
length and dates of the student's assignment.
NNP Students ONLY
USA/Faculty: Notify Pediatrix (preceptor) of planned
schedule of each student’s assignment, including
name, level of clinical training, length and dates of
student’s clinical experience.
Students: Must have the following within 90 days of
admission to the clinical experience; background
Check, to include SLED required in South Carolina,
National Sex Offender, OIG List, Federal and
National Criminal File Search.
Must complete the Hospital’s orientation and
registration. Must complete Confidentiality
Agreement available from Hospital.
64
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Pen Bay Medical Center
Rockport, Maine
Peninsula Regional Medical Center
Salisbury, MD
BSN, RN-BSN, MSN,
DNP
RN-BSN, MSN, DNP
Penn State Milton S. Hershey
Medical Center
Hershey, Pennsylvania
Phoebe Putney Health System
Albany, Georgia
Phoenix Children’s Hospital, Inc.
Phoenix, Arizona
Physician Groups, LC dba BJC
Medical Group of Missouri
St. Louis, Missouri
BSN, RN-BSN, MSN,
DNP
Piedmont Healthcare, Inc. (facilities
covered by agreement: Fayette
MSN, DNP
NP
Agency contact for USA Faculty is Paula Delahanty,
RN, BSN, MHSA. 207-596-8547
pdelahanty@penbayhealthcare.org
USA/Faculty: Make available to Agency names of
students, dates and times of experience and student
learning objectives at least 2 weeks prior to
placement(Patricia Serkes 410-543-7412patricia.serkes@peninsula.org). Give a copy of the
Agency’s Infection Prevention Manual to each
student participating in clinicals.
Student: Must have all adult immunizations as
determined by the Maryland Department of Health
and Mental Hygiene and the Immunization Practices
Advisory Committee. Must be vaccinated against the
Hepatitis B.
USA/Faculty: Provide education programs regarding
OSHA compliance standards for students prior to
clinicals.
Student: Provide proof of an annual physical
examination and provide immunization records.
Student must complete Attachments B & C prior to
beginning clinicals.
USA/Faculty: Provide facility with student
names, health status reports, immunizations
prior to cliniclas. Verify each student has
completed and passed the requirements noted
in Exhibit 2.
Students: Complete Exhibit 2-Confidentiality
Statement. Provide facility with proof of health
insurance.
Community Hospital, Inc.
d/b/a Piedmont Fayette Hospital
Piedmont Heart Institute, Inc.
Piedmont Heart Institute Physicians, Inc.
Piedmont Healthcare Foundation, Inc.
Piedmont Henry Hospital, Inc.
Piedmont Hospital, Inc.
Piedmont Medical Care Corporation, Inc.
Piedmont Mountainside Hospital, Inc.
Piedmont Newnan Hospital, Inc.
Atlanta, Georgia
Piedmont HealthCare
Statesville, North Carolina
USA/Faculty: Provide Agency with overall objectives.
Student: Must complete Exhibit A-Student
Participation Agreement. Must maintain personal
health insurance. Complete Piedmont’s Student
Orientation Presentation and PHC Code of Conduct
as required by Agency.
USA/Faculty: Submit written information
regarding any course objectives or instructional
goals in respect to clinicals. Student must be
trained by School with respect to OSHA
guidelines for blood borne pathogens, TB, and
other required General Health Care Industry
Standards. Must execute confirmation of
placement in the Schedule 1 form.
Student-Must have verification of Hepatitis B
vaccination or an OSHA approved declination
form on file. Documentation will be available to
65
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
facility upon request for a period of 3 years.
Must maintain health insurance coverage.
Pikeville Medical Center
Pikeville, Kentucky
BSN, RN-BSN, MSN,
DNP
Pinehurst Medical Clinic
Pinehurst, North Carolina
Pinnacle Health (Pinnacle Health Hospitals,
BSN, RN-BSN, MSN,
DNP
MSN, DNP
Pinnacle Health Medical Services, Pinnacle
Health Cardiovascular Institute, Pinnacle Health
Medical Group)
USA/Faculty: Must complete exhibit A (the document
has been appropriately signed by the Director for
Clinical Affairs). Supply agency’s rotation supervisor
with appropriate forms to be used in evaluating
student’s performance.
Student: Complete and submit Exhibit B-Statement
of Understanding.
USA Faculty and Students please see the
updated Student System Requirements and
Criminal Offenses List.
USA/Faculty: Submit names of the students and
related documents to facility at least 4 weeks prior to
clinicals.
Students: Students: See Student website:
http://www.pinnaclehealth.org/JobOpportunities/Student-Career-Information.aspx
Harrisburg, Pennsylvania
Planned Parenthood of the
Heartland
Des Moines, IA
Planned Parenthood of Houston and
Southeast Texas, Inc. (covers the
Planned Parenthood of the Gulf
Coast)
Houston, Texas
RN-BSN, MSN, DNP
Planned Parenthood of SW &
Central Florida
Sarasota, Florida
BSN, RN-BSN, MSN,
DNP
Encouraged to obtain hospital health insurance
coverage. Provide proof that student has had no
conviction of any crimes listed in the Pinnacle Health
Criminal Background check and Offense Policy.
Must complete facility's online education regarding
blood borne pathogens, standard precautions, the
process of reporting exposures, information of
hazardous substances, and importance of having
exposures evaluated and treated. Must complete
Pinnacle Health's online education regarding the
application of Pennsylvania's Medical Care and
Reduction Act to hospitals.
Contact:
Christine Jaynes Contreras
christine.jaynescontreras@ppheartland.org
MSN
66
USA Faculty must submit Exhibit A (Curriculum)
to agency and at least 2 months in advance
(unless otherwise agreed upon) submit a
proposed schedule of student assignments and
type of clinical education and training required.
Planned Parenthood may require a preplacement interview with student. Students must
meet criminal background screening
requirements, as set forth on Exhibit B. Students
must maintain health insurance covering injuries
or illness.
Faculty please send any requirements to: Lauren
Brenzel lauren.brenzel@myplannedparenthood.org or
questions : 941-365-3913 x 1005
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
PLLCS Faro MD & Faro MD
Houston, Texas
Pottstown Memorial Medical Center
Pottstown, Pennsylvania
Premier Community Healthcare
Dade City, Florida
RN, RN-BSN,
MSN, DNP
NP
Student: Complete Addenda 4 & 5. Must have health
insurance during clinical rotation at Facility.
BSN, RN-BSN, MSN,
DNP
USA/Faculty: See attached required documentation.
Agency contact: Christina LaCrossCLaCross@hcnetwork.org. Submit student details
(year student, site interest, subspecialty, hours, and
dates) prior to any other documentation.
Student must sign and complete Exhibit B prior to
beginning clinicals.
Presbyterian Healthcare Services (to
include Presbyterian Hospital,
Presbyterian Rust Medical Center,
Lincoln County Medical Center,
Kaseman Hospital, Espanola Hospital,
Dr. Dan C. Trigg Memorial Hospital,
Plains Regional MC, Socorro General
Hospital )
Albuquerque, New Mexico
Privy Oasis, LLC
Grapevine, Texas
ProHealth Care, Inc. (to include:
RN-BSN, MSN, DNP
USA/Faculty: Provide names and dates of students
participating at least 3 weeks in advance to Lois
Surges lois.surges@phci.org 262-928-4403.
Students: Must have health insurance which
provides coverage for emergency services while
enrolled in program. Must complete the criminal and
caregiver background check required by Wisconsin
Statutes. Completion of training infection control,
OSHA, MSDS, Blood borne pathogen.
Waukesha Memorial Hospital, Oconomowoc
Memorial Hospital, ProHealth Care Medical
Assoc., Medical Centers)
Waukesha, Wisconsin
Promise Healthcare d/b/a Frances
Nelson
Champaign, Illinois
Providence Health and Services
(Oregon Region)
Portland, Newberg, Hood River,
Seaside, Medford
Portland, Oregon
Background check must be dated less than two
years prior to practicum. Any adverse results must
be shared with the hospital. Background check
verification letter required. HIPAA – DVD and
brochure reviews required.
USA Faculty- shall provide facility with program
curriculum and objectives.
Students-Must be educated regarding universal
precautions, blood-borne pathogens, and other
appropriate OSHA standards prior to beginning
clinicals. Students must complete checklist for
compliance at facility (see attached). It is
encouraged that student obtain health and accident
insurance.
Faculty: Students and their perspective sites
must be approved by the Oregon Board of
Nursing through USA’s Contract Office. USA
Faculty must have a Oregon APRN license.
Non-employees must: complete an Alaska
background check; orientation prior to beginning
Providence Health & Services –
67
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
clinicals.
Faculty: Must provide agency with a list of students
before they begin clinicals. Student Rotations
Coordinator: Amanda Patterson
Amanda.Patterson@providence.org (907) 212-6580.
USA/Faculty: Will assure that students are educated
regarding universal precautions, blood-borne
pathogens, and other appropriate OSHA standards
prior to clinicals.
Students: Must have criminal background check
pursuant to Hospital Policy and “Child and Adult
Abuse Laws.” Must include a search on the System
for Award Management (SAM) on the background
check (http://www.sam.gov).
Washington d/b/a Providence Health
& Services Alaska Region
Anchorage, Alaska
Providence Health & Services Washington d/b/a Providence
Centralia Hospital (to include
Providence Regional Medical Center
Everett and Providence Medical
Group-NW Washington Service
Area, Providence Medical Group
Monroe)
Centralia, Washington
Providence Hospital
Mobile, Alabama
USA/Faculty: Provide the following to the agency:
Documentation of Hepatitis B vaccination.
Documentation of two step mantoux PPD skin test
within last year.
Documentation of history of chickenpox and
vaccination history of measles and rubella.
Documentation of most recent Tetanus Toxoid
injection.
Documentation of annual Blood borne Pathogen
training from University or in the alternative to require
students to attend agency’s training session.
Students must complete departmental orientation to
specific Blood borne Pathogen issues.
USA/Faculty: Please see addenda 1-3 and the
student verification checklist.
Student: Must completed addenda 4-5 and the
student verification checklist. Must obtain and
maintain health insurance coverage.
Punta Gorda HMA, LLC d/b/a
Bayfront Health Punta Gorda
Punta Gorda, Florida
Q
R
Rady Children’s Hospital
San Diego, California
NP
68
USA/Faculty: Inform Facility in writing of level of
training each student has received prior to clinicals.
Upon request, provide Facility with a copy of each
student's academic/educational record. Provide
Facility with current information about its curriculum
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
and clinical educational goals and objectives and
promptly forward to Facility any change to its
curriculum or clinical educational goals prior to the
date of such change. Provide student's name and
other relevant information to Facility at least 30 days
prior to clinicals. Any change to student assignment,
must be made at least 2 weeks in advance of the
start of assignment, if change or cancellation is last minute USA Coordinator shall call Facility Clinical
Coordinator immediately. USA must notify Facility in
writing of names of students and faculty coming to
Facility no later than 2 weeks prior to beginning of
student assignment. Facility contact: Mara
McSparran-Project Coordinatormmcsparran@rchsd.org.
Student: Background check must be completed no
later than 30 days prior to clinical and it to be
complete annually while student is at Facility. Must
include the disclosure of all counties of residence or
work. If student leaves the School's program for 30
days or longer, other than regular scheduled
summer break, background check must be
completed before student's return to facility.
Ralph H. Johnson VA Medical
Center
Charleston, South Carolina
Rapides Regional Medical Center
Alexandria, Louisiana
University Medical Center of El Paso
(formerly R.E. Thomason General
Hospital)
El Paso, Texas
MSN
RN-BSN, MSN,
DNP
RN, NP
Reading Hospital (BEGINS
1/1/2015)
West Reading, Pennsylvania
69
USA/Faculty: Please complete required TQCVL with
student information. Send to Mary Meyer mmeyer@southalabma.edu, she will verify the
completion of requirements on the form. Mary will
give to me to obtain Dr. Rhodes signature, I will then
send on to Mr. Williams.
Student: Please request facility letter detailing your
requirements.
USA/Faculty: Complete Exhibit C and submit to
Agency (Shelley DauzatShelley.Dauzat@hcahealthcare.com)
Student: Must complete Exhibit A & B.
Students must complete agency’s Non-Disclosure
Agreement and the last page of Code of Conduct
Manual. Also students must attend orientation
provided by the hospital prior to beginning clinicals.
Students must comply with the agency’s regulations
regarding Electronic Media (if applicable, please see
Addendum E). Student may need to supply the
agency with a background check that includes
personal references and their credit history if
applicable.
USA/Faculty: Ensure that every Student selected for
Clinical Training has been educated as to the
requirements to maintain confidentiality and privacy
of protected health information in a hospital or
community-based practice in accordance with state
and federal law, including but not limited to the
Health Insurance Portability and Accountability Act
of 1996, as amended, and its implementing
regulations (“HIPAA”), applicable requirements of
federal and state laws and regulations governing the
Clinical Training area and has signed and agreed to
comply with the terms and conditions in the
Statement of Confidentiality and Consent form,
attached hereto as Exhibit B.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Student: Must obtain a Criminal Record Check and a
Child Abuse History Clearance.
Physical Examination
Proof of immunity against measles, mumps, and
rubella (defined as a series of two MMR vaccines OR
positive titers to all three diseases);
Two negative tuberculin skin tests (TST), one within
the past year; if TST positive, a negative chest X-ray
report within the past year is required;
Either a completed Varicella series or a positive
antibody test documenting immunity to Varicella;
Proof of immunity against Hepatitis B, (defined as a
series of three Hepatitis B vaccines; a post-series
titer is not necessary) OR a signed declination;
Proof of influenza immunization with current
seasonal influenza vaccine, or request for exemption
(if exemption has been granted, student will be
required to wear a surgical mask during clinicals
during flu season; and
Proof of Tdap (tetanus, diphtheria, pertussis)
vaccination.
Complete Exhibit B.
Regional Health
Rapid City, South Dakota
Regional Medical Center of
Acadiana
Lafayette, Louisiana
Regional One Health (Outpatient
Centers)
Memphis, Tennessee
Regional One Health (Regional
Medical Center at Memphis)
Memphis, Tennessee
MSN
Student: Must complete Attachment 1.
Students must sign Exhibits A and B prior to
beginning clinicals. Faculty must complete Exhibit C
once Mary Meyer has verified.
Undergraduate and
Graduate
MSN, DNP
The agency is requesting that, prior to clinicals,
student needs to be found free from communicable
disease based upon a current health screening. At a
minimum, each student will have rubella titer and
annual tuberculin testing preformed, with the results
forwarded to the clinical coordinator of the Hospital.
A measles vaccine shall be given and hepatitis B
vaccine shall be offered, unless documented
immunity can be established to the satisfaction of
Hospital. In the event a student elects not to have
the hepatitis B vaccine initiated after the
risks/benefits have been fully explained, USA shall
obtain from student an appropriate statement
documenting such refusal.
Student must have proof of influenza vaccination
(this may be included with the attestation form) or to
wear a mask during flu season.
River Oaks Hospital
Jackson, Mississippi
Nursing
70
Written student evaluation of each clinical rotation
and copy of the curriculum, clinical objectives, and
student's skill and competency skills.
FACULTY: Please send required exhibits
(available from the contract office to Barbara
Boulton -bboulton@the-med.org.
They can accept these forms electronically.
USA/Faculty: See Addendum 1 & 2 -Patient Care
Duties.
Student: Complete Addenda 4, 5, and 7.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Robert Wood Johnson University
Hospital
New Brunswick, New Jersey
RN-BSN, MSN,
DNP
USA/Faculty: Provide written document on USA
Letterhead to agency regarding student's
background check (see template provided by USA
Clinical Affairs).
Students: MUST OBTAIN AND MAINTAIN THEIR
OWN GENERAL LIABILITY INSURANCE with limits
of not less than $1,000,000 per occurrence and
$3,000.000 in the aggregate.
The student must show written
documentation of the following:
Hepatitis B vaccination or refusal
Negative Tuberculin Skin Test (TST) must
have been tested within the last 12 months or
documentation of negative two - step TST.
Student's immunity history for varicella, rubella,
and rubeola. (If previous rubella is not in the
history, and titer is negative, a rubella vaccine
shall be required.
Influenza vaccine within the past twelve
months or refusal.
Roper St. Francis Healthcare
Charleston, South Carolina
Rush Health System (to include all of its
subsidiaries and affiliated entities)
Meridian, Mississippi
Rush Oak Park Hospital
Oak Park, Illinois
Rush University Medical Center
Chicago, Illinois
BSN, RN-BSN,
MSN, DNP
BSN, RN-BSN,
MSN, DNP
Graduate
Faculty and Students please see Exhibit C for list
of agency requirements.
S
Saad’s Health Care
Mobile, Alabama
Sacred Heart Health System
Pensacola, Florida
Agency contact: Beth Menahbmenah@shhpens.org.
Students must review Exhibit A and complete
Application for Residents and Students prior to
starting clinicals. See course coordinators. Students
must follow flu vaccine policy, available through the
contract office.
USA/Faculty: USA must certify the student has
completed the required training in HIPPA compliance
and blood and body fluid standard precautions
consistent with the Center for Disease Control
guidelines. Must provide Facility with course
objectives for the program prior to the beginning of
clinicals. All student information requested from
Facility must be submitted within 2 weeks of student
beginning clinicals.
Saddleback Memorial Medical
Center
Laguna Hills, California
Students: Must maintain adequate healthcare
coverage. Must have received training in HIPPA
71
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
compliance and blood and body fluid standard
precautions consistent with the Center for Disease
Control guidelines. Also to complete any Facility
orientation requirements.
Saint Alphonsus Health System (to
include: Nampa, Idaho and Boise,
Idaho)
Boise, Idaho
MUST BE RESIDENTS OF IDAHO
OR OREGON
USA/Faculty: Please see Exhibits A & B for
Background Check and Immunization Requirements.
Provide written notice to agency not less than 45
days prior to start date (Internship Request).
Request must contain, student name, desired
profession of Internship, the Saint Alphonsus facility,
Preceptor name, start date, desired length of
Internship, Letter of good standing. In the event
student will perform any research, USA shall
disclose any Research it is then aware of in the
Internship Request. Provide annual report that
summarizes Internship to indicate the extent to which
the objectives were fulfilled. Contact: Kim Philipps
208-367-2159 or philipka@sarmc.org
Student-May be required to participate in interview
either by phone or in person, Complete and Sign
Exhibits C -Confidentiality Agreement and Exhibit DStudent Agreement.
Graduate advisor to confirm background check w/
agency and faculty to contact agency prior to
students beginning clinicals.
Student: Must complete Exhibit A-Statement of
Responsibility and Exhibit B-Confidentiality
Statement.
Saint Francis Health System, Inc.
Tulsa, Oklahoma
Saint Francis Hospital-Bartlett
(effective 8/1/2015)
Bartlett, Tennessee
Saint Francis Medical Center
Grand Island, Nebraska
Saint Lazarus Behavioral Health,
Inc.
Macon, Georgia
Saint Luke’s Hospital of Bethlehem
Student must complete and sign Exhibit A. Faculty
please see Exhibit B. Adult Gerontological Acute
Care NP program.
Nurse Practitioner
Faculty:
Faculty and Agency will agree to the number of
students, their schedule and dates of admission at
least (6) six weeks prior the date of admission. The
specific days and hours of the student’s activities at
St. Luke’s Health System will be mutually agreed
upon by both parties.
Upon request Faculty will complete the Request for
Clinical Education Affiliation Agreement, in the form
Exhibit 1 available through the Contracts Office.
(to include locations at: 801 Ostrum St.
Bethlehem, 1736 Hamilton Blvd.
Allentown, PA, 1872 Riverside Circle,
Easton, PA, St. Luke’s Quakertown
Hospital, St. Luke’s Miners Memorial
Hospital, Visiting Nurse’s Assoc. of St.
Luke’s, Home Health/Hospice, Inc. and
St. Luke’s Physician Group, Inc.)
Students:
Background Check:
Student must complete and submit to agency the
following:
a. Student registration form.
b.
72
Student statement of responsibility.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
c.
Student must maintain and provide
evidence of current CPR certification
for the duration of clinicals .
d.
Students shall be responsible for
maintaining health insurance
coverage while in clinicals.
Drug Screen:
Must have a clear 5 panel urine drug screen test
administred by an HHS-certified lab to include:
1.amphetaphines, 2.cocaine, 3.cannabinoids,
4.opiates (including morphine, codeine,
hydromorphone, and hydrocodone) and 5.
Phencyclidine. Drug Screen Test: Drug Test
must be administered no earlier than 30
days prior to the date of beginning
clinicals.
Such other health related information and/or testing
as may be requested by St. Luke’s Health System
from time to time.
Faculty and Students: * Administration of such test
shall be required prior to student's first assignment at
PROVIDER. If a student maintains continuous
enrollment at SCHOOL and participates in a
subsequent rotation at PROVIDER, and SCHOOL
provides a written statement to PROVIDER prior
to such subsequent rotation that it has no reason
to believe that the student has not continued to
be drug- free, safe and qualified for the clinical
experience under this Agreement, then such test
will not be required for the subsequent rotation. If no
such statement is provided by SCHOOL, such test
will be required prior to the subsequent rotation.
Health Requirements: No active Tuberculosis, as
evidenced by two tuberculin skin tests showing
either (a) a negative result, (demonstrated by either
the last two consecutive annual TB skin tests dated
within two (2) years of the date of assignment at St.
Luke's OR two step TB testing - two tests dated
within one (l) year of date of assignment at St.
Luke's) or (b) if a positive result, additional
completion of a TB symptom questionnaire AND
negative chest x-ray or BAMT
Blood Assay Mycobacterium Tuberculosis test done
no earlier than three (3) years prior to the date of
assignment at the PROVIDER. History of BCG
administration without TB testing is NOT acceptable.
Saline Memorial Hospital
Benton, Arkansas
Samaritan Health Services, Inc.
Corvallis, Oregon
USA/Faculty: Provide agency with copies of
curriculum, education goals, and requirements and
qualifications of Students. Provide agency with
clinical rotation plan and clinical education objectives
73
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
for the Learning Practicum for agency’s review.
Students: Provide own health insurance.
Student’s drug screen results, background check,
scheduling of students must be provided to the
agency within 60 days prior to the beginning of
clinicals.
San Joaquin Community Hospital
Bakersfield, California
Students must carry own health insurance.
Agency contact: Alana Erstad-701-323-6375alana.erstad@sanfordhealth.org.
Sanford Health-Bismarck
Bismarck, North Dakota
Preventive health requirement form has to be
completed on student. Student must complete Net
Learning System. Mandatory influenza vaccinations
for students-October1st through March 31st.
Students must have background check
completed at least one year prior to clinicals.
ALL: please see the updated forms and information
regarding the Ebola virus: Please be advised that,
following the CDC’s recent alert regarding confirmed
cases of Ebola in the country of Mali, Sanford is now
screening for travel to Mali, as well as Guinea,
Liberia and Sierra Leone. Accordingly, attached,
please find revised versions of the Interim HR Ebola
Related Protocols and Pre-Employment Travel
Questions Guide for Recruiters, which have been
updated to include Mali as one of the Impacted
Regions. Also attached for your reference, please
find the CDC’s Interim U.S. Guidance for
Monitoring and Movement of Persons with
Potential Ebola Virus Exposure (October 27,
2014).
Sanford Health
Sioux Falls, South Dakota
Students must review and complete the Sanford
Health Orient Action Packet, please note the
directions for sending the forms. They can be faxed
to 605-312-9837 or scanned/emailed to:
STUDENTSSF@SanfordHealth.org
USA/Faculty: Program Faculty must be appropriately
licensed in the applicable state where the program
activities will be performed. Submit upon request the
program philosophy, objectives, and type of learning
experience desired. Dates, times, number, and
academic level of students assigned to clinicals.
Name, license number, and credentials of faculty
member providing practicum instruction.
Student: Must have current influenza vaccination,
physical exam showing good health, TB skin test
within the last 12 months, Hepatitis B vaccine (3
doses are recommended, but not required prior to
clinical). Provide Facility's Office of Academic Affairs
with the results of the national background check
and criminal screening, must be completed within
one year of student’s clinical at Sanford Health.
USA Faculty must provide the following to Sanford
upon request:
Program philosophy, objectives and type of learning
experience desired.
Dates, time, number and academic level of students
to be assigned to each unit within Sanford.
Name, license number, and credentials of faculty
member providing practicum instruction, if
Sanford North
Fargo, North Dakota
74
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
applicable.
Prior notice of any proposed changes to any
assigned student's schedule.
USA/Faculty: Agency contact-Michael Perry michael.perry@hhs.sccgov.org-408-885-6710.
Required annual health screening clearing student to
participate in the clinical training program with no
restrictions. Written documentation of immune status
for the following:
Rubella and Mumps
Rubeola
Varicella
Hepatitis B
Written documentation of TB screening by TB Skin
Test or Interferon Gamma Release Assay. Annual fit
test results with the health care particulate respirator
N95 in use at facility. Written documentation of flu
vaccine or completed declination form. Written
documentation of T-Dap or completed declination
form. Please see the facility's Infection Prevention
Policy under the Employee Health Infection
Prevention Program (available through facility).
Santa Clara Valley Medical Center
and Santa Clara Valley Health and
Hospital System
San Jose, California
Students: Must complete Exhibits C (Security and
Confidentiality Agreement) & D (Confidentiality of
Patient and Employee Information), submit to the
facility. Required annual health screening clearing
student to participate in the clinical training program
with no restrictions. Obtain a photographic
identification badge from the County and wear badge
at all times while participating in the clinical training
program.
USA/Faculty: Must submit all coordinating
information for student and clinical to Cindy Sallas
Director, Medical Staff Services Santa Rosa Medical
Center (850) 626-5106 cindy.sallas@hma.com. Must
complete attestation form (Exhibit C-attached) and
submit to agency.
Student: Must sign a Statement of Responsibility and
a Statement of Confidentiality (Exhibit A- Battached). Should you have any questions, please let
me know. Must secure health insurance coverage
through approved provider by Hospital.
Santa Rosa Medical Center
Milton, Florida
Santa Rosa Public Health
Department
Milton, Florida
Sarasota Memorial Health System
Sarasota, Florida
USA must notify the agency of the names
and number of students and period of
clinical four months prior to the beginning
of clinical. USA must complete and sign
Exhibit A-Attestation.
All students must have a physical exam
prior to beginning clinicals. All students
who are unable to take the influenza
vaccination will be required to wear a
surgical mask. Student must have a current
criminal background search, which may
75
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
include a Level 2 Screening, this will be the
responsibility of the student, including any
fees associated, (Exhibit B) when required.
Students in the Advanced Registered Nurse
Practitioner (ARNP) program must provide
information to the Medical Staff office.
Scott & White Memorial Hospital (to
NP Students Only
include: Scott & White Memorial
Hospital of Temple, Texas, for itself
(including the Facility using its assumed
name McLane Children’s Hospital –
Scott & White) and its affiliates Scott &
White Clinic, Scott & White Continuing
Care Hospital, Scott & White Hospital –
Brenham, Scott & White Hospital –
College Station, Scott & White Hospital
– Llano, Scott & White Hospital –
Marble Falls, Scott & White Hospital –
Round Rock, Scott & White Hospital –
Taylor, Hillcrest Baptist Medical Center,
Hillcrest Family Health Center, and
Hillcrest Physician Services (individually
or collectively “Scott & White”)
USA/Faculty: Notify agency, not less than 21 days
before the start of each clinical of all planned student
assignments, to include students' names, levels of
academic preparation, and dates of participation.
Student: Must have drug screening and background
check no earlier than 30 days before the start of the
clinical experience.
Temple, Texas
Scripps Health (to include: Scripps
RN-BSN Only
Clinic, Coastal Medical Center, Scripps
Green Hospital, Scripps Home Health,
Scripps Memorial Hospital Encinitas,
Scripps memorial Hospital LaJolla,
Scripps Mercy Hospital Chula Vista,
Scripps Mercy Hospital)
San Diego, California
Seattle Children’s Hospital
Seattle, Washington
Nurse Practitioner Students
USA Faculty: to provide objectives and course
description to agency. Send student name and bio
information at least 30 days prior to clinicals. Provide
agency with evidence of student’s required
immunizations. Must provide students with (a)
information and training on universal precautions
which include but are not limited to the hazards
associated with blood and other potentially infectious
materials. (b) protective measures to be taken to
minimize the risk of exposure to bloodborne
pathogens, (c) appropriate action to take in an
emergency involving exposure, (d) reasons the
student should participate in hepatitis B vaccination
and post-exposure evaluation and follow-up.
Documentation is maintained by the College. Submit
name and credentials of the USA faculty facilitator.
Contact agency at least once during each clinical
education period for conferring with the Center
Coordinator of Clinical Education.
Students: must show evidence of health insurance
coverage valid through course of clinicals that will
cover them in California. Must have physical exam
and negative skin test for tuberculosis within one
year of the clinical assignment. A chest x-ray is
required should the skin test be positive. Must notify
agency and College immediately whenever absence
from agency is unavoidable.
SEATTLE CHILDREN EMPLOYEES ONLY
USA Faculty: Complete Letter of Agreement
and provide to Facility. Contact: Jackie Smith -
Nursing
76
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
jacqueline.smith@seattlechildrens.org. See
Immunization and Health Requirements
document.
Students: Should obtain health and accident
insurance.
Select Specialty Hospital -Gulf
Coast, Inc.
Gulfport, Mississippi
Select Specialty Hospital
Tallahassee, Florida
Seminole Medical Center
Seminole, Oklahoma
USA/Faculty: Please see student requirements.
Student: Must acknowledge in writing to Facility that
they have review and understand the Hospital's
Policies and Procedures and have no questions
regarding the standards set forth in the Policies and
Procedures (Provided by Facility). Students must
undergo training on the HIPAA, prior to clinicals.
Must have had instruction in accordance with the
federal guidelines "Occupational Exposure to
Bloodborne Pathogens" and instruction in exposure
to tuberculosis, protective practices to avoid
contamination, and procedures in case of exposure
or potential exposure in accordance with the federal
guidelines "Guidelines for Preventing the
Transmission of Mycobacterium Tuberculosis in
Health Care Facilities". Must have PPD within the
last year showing on record freedom of tuberculosis.
Student must show they have either received Hep B
vaccine or signed a declination form.
MSN and NP
USA/Faculty: Must receive a copy of
student’s professional liability insurance
for the file.
Sentara Healthcare System
(includes: Sentara Bayside Hospital,
Sentara Leigh Hospital, Sentara
Norfolk General Hospital, Sentara
Careplex Hospital, Sentara Virginia
Beach General Hospital, Sentara
Williamsburg Regional Medical
Center, & Sentara Louise Obici
Memorial Hospital)
Students: must purchase professional
liability insurance (outside of USA) in a
minimum amount equal to not less than the
limitation on recovery per occurrence specified
in Section 8.01-581.15 of the Code of Virginia
( current code is available from the USA
Clinical Affairs Department) in order to intern at
this site, since Virginia law requires higher
limits that the University offers.
Chesapeake, Virginia
Seton Medical Management
Mobile, Alabama
Severna Park Center
Annapolis, Maryland
Shands Jacksonville Medical Center
Jacksonville, Florida
USA/Faculty: See Addendum 1-3.
Student: Must complete Addendum 4 & 5. Must have
health insurance.
Nurse Practitioner
Students must maintain health insurance coverage
while in clinicals at Facility.
ALL REQUESTS FOR CLINICAL ROTATIONS
MUST COME FROM FACULTY. Students must
have photo student ID and complete Shands’
orientation prior to beginning clinicals. Exhibit A
requirements from student and faculty. ALL
REQUESTS FOR CLINICAL ROTATIONS MUST
COME FROM FACULTY. Faculty should contact
77
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Shands Lake Shore Regional
Medical Center
Lake City, Florida
Nurse Practitioner
Christy Eads. Email: christy.eads@jax.ufl.edu
Phone: 904-244-1925 and she will provide Shands’
orientation packet.
Student: Complete Addenda 4 & 5 - submit to
agency. Must have OSHA Blood borne pathogens
standards and tuberculosis transmission prevention
training prior to clinicals. Must have health insurance
during their clinicals at Facility.
Students must complete Exhibit A before starting
clinicals. (NON EMPLOYEES ONLY).
Shands Teaching Hospital and
Clinics d/b/a Shands at the
University of Florida (Shands at
Vista and Shands Rehab Hospital)
Gainesville, Florida
Sharp HealthCare
San Diego, California
Family Psych and
Nursing Informatics
NURSING INFORMATICS and FAMILY
PSYCHIATRIC NP PROGRAM ONLY
Preceptors must be
SHARP Employees
(does not include
Medical Staff)
Students must complete Exhibit A before starting
clinicals.
ALL REQUESTS FOR CLINICAL ROTATIONS
MUST COME FROM FACULTY. Agency contact:
Jean Bulmer-bulmej@shands.ufl.edu
Faculty: must contact Claudia Bock at 858-4995366 or by email at claudia.bock@sharp.com to fill
out a roster of students being placed at Sharp.
Faculty who will be on site with students need to
contact Barbara DeFulvio at 585-499-5244 or
Barbara.Defulvio@sharp.com. Faculty web site is
www.sharp.com/b2b/students.index.cfm
Students: need to access the following web site
www.sharp.com/b2b/students.cfm.
To make sure that the students background checks
and drug screening requirements are complete,
please see Attachment A.
Agency may require the student to purchase full “tail
“insurance to cover student’s activities during term of
agreement.
Sheridan Children’s Healthcare
Services, Inc.
Plantation, Florida
Sheridan Children’s Healthcare
Services and South Broward Hospital
District d/b/a Memorial Healthcare
System (Memorial includes: Memorial
Neonatal Nurse
Practitioner
Program
Students ONLY
Faculty must submit Letter of Understanding to
Memorial for each student. Student may be required
to purchase general liability insurance if applicable.
Regional, Memorial Regional Hospital South,
Joe DiMaggio Children’s Hospital, Memorial
Hospital Pembroke, Memorial Hospital West,
Memorial Hospital Miramar)
Hollywood, Florida
Faculty must send a Program Letter to Ms. Beverly
Bernard at Beverly.bernard@va.gov, letter must
identify faculty, including VA employees, who will
teach, supervise, and evaluate trainee performance;
outline educational objectives; specify periods and
clinical area of assignments.
Sheridan VAMC
Sheridan, Wyoming
Silver Lake Medical Center
(Success Healthcare, LLC)
Los Angeles, CA
78
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
USA must provide written notice to Facility of student
placement request at least 30 days prior to their
arrival, to include student name and class objectives.
Student must have educational training in Blood
borne Pathogens, BLS, Sliverton Health online
competency lessons. Flu Vaccine (OctoberMarch). Facility contact: Jocelyn Lewis at
jlewis@silvertonhealth.org or 503-873-5292.
Silverton Health
Silverton, Oregon
Faculty: Students and their perspective
sites must be approved by the Oregon
Board of Nursing through USA’s Contract
Office. USA Faculty must have a Oregon
APRN license.
Singing River Health System
(renewal request sent, set to expire
6/1/2016)
Pascagoula, Mississippi
Sisters of Charity Providence
Hospital
Columbia, South Carolina
Faculty should contact Tajuane Dockery 803-8654793 tajuane.dockery@providencehospitals.com to
schedule students participating in clinicals.
Students complete Exhibit B.
Student must complete and sign Exhibit A&B,
Addendums A-C. USA Faculty please submit the two
attestations forms to
Gail/Mary Meyer for Dr. Rhodes signature before
sending to the student.
USA/Faculty: Must provide the following to agency at
least 3 weeks prior to actual assignments:
Roster of Students (including list of competencies
and evaluation forms.
Clinical practice assignments with scheduled
rotations.
Brief name of course description for the required
learning experience.
USA Faculty: Must provide all objectives, policies,
and evaluation instruments to be utilized to
preceptors. Review Exhibit A (Immunization
Requirements).
Skyline Medical Group
(renewal request sent, set to expire
6/2016)
Nashville, Tennessee
Slidell Memorial Hospital & Medical
Center
Slidell, Louisiana
Soin Medical Center (Kettering
Health Network affiliate)
Beaver Creek, Ohio
Students: Must complete and sign Exhibit B. Must
provide Hospital with documentation evidencing
background check. Must provide proof of health
insurance to Hospital.
Student must provide written evidence of negative
TB test within the past year or chest x-ray within last
3 years, written documentation of a completed
Hepatitis B vaccine or one has begun the series.
Students must submit to substance abuse testing
every 12 months (to test for presence of alcohol,
drugs, or other controlled substances).
South Baldwin Regional Medical
Center
Foley, Alabama
South Carolina Department of
Health and Environmental Control
Columbia, South Carolina
Nursing
South Carolina Department of
79
USA/Faculty: Provide to Agency names of
students, objectives and dates for each
student in a clinical experience at Agency.
Student: Must obtain Health Insurance during
experience.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Mental Health (Division of Inpatient
Services)
Columbia, South Carolina
Southcoast Hospitals Group, Inc.
New Bedford, Massachusetts
Students and on-site instructors must complete 10
panel urine drug tests prior to beginning clinicals.
Students must complete the student/Instructor
Confidentiality Agreement.
South Jersey Hospital, Inc. (aka
Bridgeton Mental Health Unit)
Bridgeton, New Jersey
South Lake Hospital
Clermont, Florida
Southeast Alabama Medical Center
Dothan, Alabama
Southeast Regional Primary Care
Corporation (to include Dublin Internal
USA/Faculty: Provide written clinical behavioral
objectives to facility prior to clinicals. Submit a
schedule with names of students at least two weeks
prior to clinicals. (Priscilla Edge-Payer Enrollment
Administrator-912-538-5314pedge@meadowsregional.org)
Student: Submit health records to facility at least two
weeks prior to clinicals. Urine Drug Screen may be
requested by facility. If student has had a break in
enrollment, student will need new background check.
Agreement covers preceptor at said facility only.
Medicine and Vidalia Women’s Center)
Vidalia, Georgia
Southeastern Emergency
Physicians, LLC & Southeastern
Emergency Services, P.C.
(in accordance with the Maury
Regional Hospital agreement)
Knoxville, Tennessee
Southern Illinois Hospital Services
CNS Students Only
USA/ Faculty: Not less than one week prior to
clinicals, provide a list of Students to appropriate
departments at facility, physical exam within last 12
months, evidence of TB test (step 2), chest x-ray for
students with a positive TB skin test, MMR
immunization, Hepatitis B vaccine, or provide a
signed waiver, screen for varicella immunity, valid
current certification in CPR. Provide information and
training regarding exposure to blood borne
pathogens consistent with the standards applicable
for compliance with the final regulations issued by
OSHA.
Student: Maintain health insurance during their
participation in the program at facility. Attend all
required orientation at facility. Must obtain a
successful completion of a urine drug test within
seven days prior to clinical start date. Student
must report to WorkCare (500 Lincoln Drive, Suite D,
Herrin, Illinois) for pre-assignment testing. Failing the
drug test will result in withdrawal of clinical
assignment for one year.
Student: Must have a criminal background check
within a 90 day period immediately prior to their initial
placement at facility. Must complete an infection
control in-service training, emergency procedure
(to include: Memorial Hospital of
Carbondale, Herrin Hospital, St. Joseph
Memorial Hospital)
Carbondale, Illinois
Southern New Hampshire Health
System
Nashua, New Hampshire
80
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
training, and an orientation program at facility. Will
receive a copy of the Patient Bill of Rights from
agency and sign a statement that such copy has
been has been received and they understand their
responsibilities with regard to patient rights. Must
maintain health insurance coverage. Must have an
annual TB test while at facility. Must provide
documentation of OSHA education.
USA/Faculty: Instruct all students in the
confidentiality of patient/client records and these
requirements are to survive the termination or
expiration of agreement. Must submit all required
student information to facility Director Medical Staff
Services (Meghan Higman mhigman@swhealth.org) at least two weeks prior to
clinicals. Student name, Drug-free status report, TB
Skin Test, Influenza vaccine for current flu season,
up-to-date vaccine history,
Student: May be subject to drug tests at any time at
the initiative and in the sole discretion of facility.
Southwest Health System
Cortez, Colorado
Student: Complete Exhibit B-Acknowledgement of
Confidentiality and Exhibit C-Acknowledgement of
Non - Employee Status. Provide documentation of
current physical examination and up to date
immunization status, including Hepatitis B
vaccination.
Southwest Public Health District 8,
Unit 2 (Southwest Georgia Health District)
(encompasses clinical facilities in Georgia
counties of Baker, Calhoun, Colquitt,
Decatur, Dougherty, Early, Grady, Lee,
Miller, Mitchell, Seminole, Terrell, Thomas &
Worth)
Albany, Georgia
Southwestern Regional Medical
Center, Inc.
Tulsa, Oklahoma
USA/Faculty: Please review Exhibit B for Program
Specific Requirements. Must provide evidence that
each student has met all requirements of CPR
certification, hepatitis B vaccination, and OSHA
compliance for prevention of transmission of blood
borne pathogens and TB.
Student: Meet the personal, ethical and professional
standards required of employees of the facility and
consistent with the applicable professional Code of
Ethics and the applicable standards of The Joint
Commission and/or other relevant accrediting or
regulatory bodies.
Agency may require USA Faculty to provide names
of students as well as confirmation of various
disclosures and /or training requirements. Students
must complete Exhibit A.
Faculty, provide information regarding curriculum
and clinical education goals associated with the
clinical rotation. Must notify agency within 1 month in
advance to change student assignment. Faculty
must complete a student profile from the agency to
include a picture of the student (for ID purposes)
specific dates of the clinical rotation.
Students must maintain Health insurance coverage
during clinical. Students must have had physical
exam prior to beginning of clinical rotation.
USA/Faculty: Exhibits A-C must be completed by
student; Faculty will be the contact person for
student. Submit all requested student information to
facility within 30 days prior to clinicals.
Spartanburg Regional Health
Services District, Inc.
Spartanburg, South Carolina
Speare Memorial Hospital
Plymouth, New Hampshire
Springboro Family Medicine (only
with preceptor, Dr. Dori Thompson)
Dayton, Ohio
81
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Springhill Memorial Hospital
Mobile, Alabama
SSM Health
St. Louis, Missouri
MSN, DNP
Student: Must have satisfactory health status as
determined by the standards of the Ohio Dept. of
Health CDD and Hospital, as delineated in Exhibit A.
Must provide proof of health insurance. Must
complete Exhibit A-C. Must continuously maintain
RN licensure in the State of Ohio during the term of
agreement (September 8, 2014-September 7, 2015).
Student may not document in either the History &
Physical or Discharge Notes portions of said
permanent medical record.
University is required to provide results of any drug
or alcohol tests to the Agency prior to a particular
student’s clinical rotation. As an alternative to
providing the test results to the Agency, the
University may certify the student has been tested
and no evidence of drugs or alcohol was found. The
Agency may at its sole discretion require a student to
undergo drug and/or alcohol testing to continue a
clinical rotation at the Agency.
USA/Faculty: Submit upon request student
information (names, health status reports,
immunization records, etc.).
Student: Must complete Exhibit 1-Confidentiality and
Security Agreement. In addition For FACILITY sites
in the state of Missouri, Student shall comply with the
background check provisions of the regional
guidelines for allied health/nursing districts of the St.
Louis Metropolitan Hospital Council.
St. Cloud VA Medical Center
St. Cloud, Minnesota
(Minnesota sites should only
be utilized by approved USA
students)
St. David’s Healthcare Partnership,
L.P., LLP (to include: St. David’s Medical
MSN NP
*On-site USA Faculty/Staff must drug/alcohol test*
USA/Faculty: Must complete Exhibit D-Student
Attestation. Agency contact is Gail RobertsGail.Roberts@hcahealthcare.com-512-544-0108.
Center, St. David’s Rehabilitation Hospital, Heart
Hospital of Austin, St. David’s Georgetown
Hospital, St. David’s North Austin Medical Center,
St. David’s Round Rock medical Center, St.
David’s South Austin Medical Center)
Student: Must complete Exhibits A & B. Must have
yearly medical examination.
Austin, Texas
St. Dominic-Jackson Memorial
Jackson, Mississippi
Students:
Students cannot have a GPA of lower than 2.0 in the
nursing curriculum. Must have annual physical
examination. Must have completed a training
program for the prevention of the transmission of
blood borne pathogens.
USA/Faculty: Provide advance notice to agency of
the dates and number of students and for clinicals
each period. Provide a copy of the student’s
schedule indicating holidays and other closures.
St. Elizabeth Physicians Group
Crestview Hills, Kentucky
Student: Must obtain health insurance coverage for
the entire term of their clinical. Must read and sign
the Statement of Understanding.
* Agreement for Advanced Emergency Nurse
Practitioner Students Only*
USA/Faculty: Complete Exhibit C-Attestation.
St. Francis Hospital
Memphis, Tennessee
Students: Must complete Exhibit A-Statement of
82
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Responsibility and Exhibit B-Confidentiality
Statement. Must have received OSHA training
pertaining to exposure to blood borne pathogens in
the workplace.
St. John Medical Center, Inc.
Tulsa, Oklahoma
USA/Faculty: Please provide a roster of student/
faculty names and rotating schedule to agency
contact: Ebony Fultz-ebony.fultz@sjmc.org-918-7443602. Students must have OSHA training. Please
see exhibit for programs involving research.
Student: Please provide verification of the following:
Immunizations
Drug test
Verification that immunity requirements are met and
supported by documentation for: Mumps, Rubella,
Rubeola, and Varicella; verification of Hepatitis B
vaccination in accordance with recommendations of
OSHA; TB test within past 12 months; verification of
influenza vaccination or documentation of
declination. CPR certification.
Background check from state of residency run within
1 year of first clinical at facility.
St. Francis Physician Services/St.
Francis Hospital
Greenville, South Carolina
MSN and DNP Students.
USA Faculty:
Students: Must meet facility’s policy regarding fire
safety and blood-borne pathogen training. Must read
the Bon Secours Health System Code of Conduct
before reading and signing the student agreement.
St. Joseph’s /Candler Health
System
Savannah, Georgia
Covered programs are:
Acute Care NP
BSN
Emergency NP
MSN FNP
Pediatric NP
Faculty please see Exhibit A (agency attachments
list)
Student must have current physical. Students must
maintain health insurance with proof to agency
being provided upon request.
St. Joseph Regional Medical Center
Lewiston, Idaho
USA/Faculty: Please complete Exhibit B-Verification
of Required Documentation Statement, two weeks
prior to the beginning of clinicals. Ensure students
have received in compliance with OSHA BloodBorne Pathogen Regulations and infection control
procedures prior to clinical experience.
Student: Must complete Exhibit C-Student
Agreement-Clinical Experience.
USA/Faculty: Shall provide a Roster of the names of
the Students, along with a rotation schedule, to St.
Jude before the Rotation begins. Provide Letter of
Good Standing for each student to facility- Emily
Kyzer-Browne 901-595-3606
emily.browne@stjude.org..
Student: Must obtain drug screening by the
Department of Human Resources Office of
Occupational Health at St. Jude. Background checks
must be completed within the ninety (90) day period
immediately prior to the Student’s initial placement.
St. Jude Children’s Research
Hospital
Memphis, Tennessee
83
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Must obtain medical insurance and provide copy to
USA. Complete
Exhibits A & B.
Faculty, please request a copy of the “additional
terms” form prior to students beginning clinicals
St. Louis Children’s Hospital
St. Louis, Missouri
St. Luke’s Health System, Ltd. (to
include St. Luke’s Regional Medical
Center – Boise, St. Luke’s Regional
Medical Center – Meridian, St.
Luke’s Magic Valley Regional
Medical Center (Twin Falls), St.
Luke’s Wood River Medical Center
(Hailey-Ketchum), St. Luke’s McCall
- McCall, St. Luke’s Eagle Medical
Plaza Mountain States Tumor
Institute, St. Luke’s Clinics, St.
Luke’s Jerome-Jerome, St. Luke’s
Elmore – Mountain Home
Boise, Idaho
Rotation Start Dates & St. Luke’s Application
Deadlines:
Rotation Start Dates
Application
Deadline
July 1st to December 31st January 1st
January 1st to June 30th
July 1st
St. Mary Emergency Group, LLC at
Teche Regional Medical Center
Lafayette, Louisiana
St. Mary’s Health, Inc.
Evansville, Indiana
RN-BSN, MSN, DNP
USA must provide agency with student names at
least 30 days prior to beginning of clinicals. USA
must have written agreement with Physician
(whom is to have active privileges at agency),
and copy must be provided to agency.
St. Mary Medical Center
Langhorne, PA
St. Mary’s Health Care System
Athens, Georgia
Faculty will contact agency no less than 30 days
prior to clinical in order for St. Luke’s to determine
capacity. At least 15 days prior to clinical Faculty
must provide student information and documentation
to facility. Students must complete Attachment B.
Agreement covers all Nurse Practitioner and Nursing
Programs. Must have Flu vaccination, exemption
only for strongly held religious beliefs and medical
reasons.
USA Faculty must inform students they are not
employees of Physician Group or Facility and have
NO benefits with either entity. Faculty and Student
must sign attestation l acknowledging students have
been informed and understand. Attestation available
in attachments.
USA/Faculty: Notify Facility of the number of
students and rotation periods four weeks prior to the
commencement of the clinical experience. Forward
students' full legal name, full social security number,
date of birth, permanent mailing address, phone
number and email address on behalf of the student
or notify the student the clinical facility must have this
information no less than 72 business hours prior to
clinical experience. Provide to Facility, statement of
philosophy and the objective of curricular and clinical
education.
Student: Must have general background and training
in blood borne pathogens and infection control
according to OSHA standards and Hazardous
Materials Awareness prior to clinical experience.
RN-BSN, MSN,
DNP
84
USA/Faculty: Provide written plans for the
Learning Experience and Student assignments
to Agency no less than 30 days prior to the
beginning of clinical. Submit to: Kimberly
Lawrence. Clinical Education Department 1230
Baxter Street, Athens, GA, 30606, 706-3892150, klawrence@stmarysathens.org.
Student: Submit the Orientation packet
(provided by Agency) to Agency at least two
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
weeks prior to clinical.
St. Mary’s Hospital & Medical
Center, Inc.
Grand Junction, Colorado
MSN, DNP
St. Mary’s Hospital
Decatur, Illinois
USA/Faculty: Please complete Exhibit A and submit
to agency at least 3 weeks prior to clinicals. Agency
contact: Pat Montgomerypat.montgomery@sclhs.net-970-298-1950. USA
Faculty must receive waiver from Agency in writing
regarding their orientation program. Must notify
Agency of any change in Program Faculty at least
two weeks prior to the start of clinicals.
Student: Must provide proficiency in written and
spoken English language. Provide Agency with
documentation of training in OSHA (including blood
borne pathogens), Universal Precautions as defined
by the Center for Disease Control and Prevention,
and CPR Cert. Must have health insurance.
MSN, DNP, and NP Students
USA/Faculty: Agency Contact-Anita Rickeranita.ricker@hshs.org-217-464-1074. Please see
Exhibit C-Program Requirements.
Student: Must have OSHA compliance for prevention
of transmission of blood borne pathogens and TB.
USA/Faculty: Must require each Program Participant
to sign a Statement of Responsibility (exhibit A) and
a Statement of Confidentiality (exhibit B).
Student: May be required to submit to a medical
examination prior to beginning clinicals.
St. Mary’s Physician Services, LLC
d/b/a Millard Henry Clinic
Russellville, Arkansas
Saint Mary’s of Michigan Standish
Hospital
Saginaw, Michigan
St. Tammany Parish Hospital
Covington, Louisiana
St. Vincent Healthcare
Billings, Montana
Faculty please complete the clinical request form
(Exhibit A). At least 3 weeks prior to clinical provide
student names and information to hospital including,
criminal background checks, drug screens,
immunization record, and proficiency in written and
spoken English language. Obtain hospital’s prior
written approval before publishing any material
relating to the Program’s or Student’s participation.
Students must provide and pay for their own
Worker’s Compensation while at the Hospital.
Students will not participate in any of Hospital’s
insurance programs or benefit program’s to include
Worker’s Compensation.
Please see required additional documents per the
agreement. Contact: Kelly Bachus - (205) 930-2744
(office)- Kelly.Bachus@stvhs.com
USA/Faculty: Obtain an agreement of a Medical Staff
Physician to assume responsibility of student.
Provide names of students, and the days and hours
of assigned clinical.
Student: Submit documentation of all requirements
to facility. Must complete Orientation Guide available
from facility. Complete Exhibit B-Confidentiality
Agreement.
USA Faculty must submit schedule indicating the
number and names of students who will be
participating and name of the faculty three weeks
prior to clinicals. Students must satisfy agency’s
requirements for background checks and drug
St. Vincent’s Health System
Birmingham, Alabama
St. Vincent’s Health System (to
include: St. Vincent’s Medical
Center-Southside, St. Vincent’s
Medical Center-Clay County)
Jacksonville, Florida
St. Vincent Hospital d/b/a Prevea
Health
(renewal request sent, set to expire
8/18/2016)
85
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
screening.
Green Bay, Wisconsin
St. Vincent Infirmary Medical Center
Little Rock, Arkansas
St. Vincent’s Medical Center, Inc.Riverside
Jacksonville, Florida
Stanford Health Care/ValleyCare
Pleasanton, California
Stanly Health Services, Inc.
Albemarle, North Carolina
Students must complete Exhibit A prior to beginning
clinicals.
USA/Faculty: Must provide a list of students being
assigned to facility in a timely manner. Complete
Educational Institution Verification Letter
Student: Must have documentation of negative TB
skin test within six months prior to clinicals. Must
participate in Facility’s quality and risk management
programs as required. Must complete required
orientation guide. Must sign the Confidentiality
Agreement prior to clinicals.
BSN, RN-BSN, MSN,
DNP
USA/Faculty: Please see Appendix A for Infection
Control requirements for students.
Student: Must be US citizen or legally authorized
residents of the US. Must complete a screening
through the North Carolina Sex Offender and Public
Protection Registry. Must complete a North Carolina
State Bureau of Investigation screening (SBI Screen
https://www.ncdps.gov) as required by NC law. Have
received training about occupational exposure and
appropriate protective measures prior to clinicals.
Undergraduate and Graduate Students
State Hospital South
Blackfoot, Idaho
Summa Health System Hospitals
Akron, Ohio
Summa Physicians, Inc.
Akron, Ohio
Swedish Health Services d/b/a
Swedish Medical Center
Seattle, Washington
Students: Must maintain health insurance and
provide proof of such insurance to agency. See
attachment for agency immunization requirements.
USA Faculty must send Goals/Objective of the
rotation and method of evaluation to agency
see exhibit II & III. Students once approved
must do the following: The URL to the GME on
boarding portal is
http://ehealth.swedish.org/gme, and she will
use the non-network affiliate application.
T
Take Care Health Systems, LLC
Conshohocken, Pennsylvania
NP
NP STUDENTS
Tallahassee Memorial HealthCare,
Inc.
NP
Faculty may need to send clinical program letter to
agency, outline available from Contract Office.
Students: Name tags must be clearly visible and
worn at all times while at the facility. Student must
notify agency prior to scheduled start time if the
student will be absent from scheduled participation in
the Clinical Program.
NP STUDENTS
Faculty may need to send clinical program letter to
86
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
agency, outline available from Contract Office.
Students must sign a Prohibition of Voluntary
Participation in Legal Action Against TMH
document: which prevents the student from ever
participating in any legal action against TMH.
Students should carefully consider their rights
before signing.
Students: Name tags must be clearly visible and
worn at all times while at the facility. Student must
notify agency prior to scheduled start time if the
student will be absent from scheduled participation in
the Clinical Program.
(Renewal request sent, set to expire
7/31/2016)
Tallahassee, Florida
Tampa General Hospital (Florida
Health Science Center and Florida
Gulf to Bay) (Florida Gulf to Bay
MSN, Emergency
NP, Acute Care NP
Contract only to be used as a 3-way
agreement with Tampa
General/Gulf to Bay/University of
South Alabama
DNP
DNP Students
Anesthesiology Associates, PA)
Tampa, Florida
Tampa General Hospital and
University of South Florida
Tampa, Florida
USA/Faculty: Student and Faculty must comply with
all applicable Hospital policies and procedures on
immunizations and communicable diseases as more
fully described in the "Employee Health Services
Guidelines for Students in Patient Care Areas."
Provide the following information:
Student: Annual TB skin testing, be vaccinated for
Hepatitis B or sign a release if declining that
vaccination. Required to get a Tampa General
Hospital badge from the hospital HR
department/return badge upon completion of
clinicals.
Agency Contact: Tabitha Welsh-twelsh@tgh.org
813-844-7235.
Tampa General Hospital
Tampa, Florida
Students and Faculty must comply with all applicable
policies and procedures as outlined in Exhibit B:
Employee Health Services Guidelines for Students in
Patient Care Area.
USA/Faculty: Number of students to be agreed upon
30 days in advance of any student's clinical
experience. Provide facility with the name(s), dates,
and hour of clinical experience and academic class
designation of student. Report to Clinical Affairs the
following information if a student was assigned to
TGH during 10/1-3/31.
# of students assigned during time frame.
# of students assigned that received flu vaccine.
# of students assigned that had medical
contraindications to flu vaccine and had to wear a
mask while in a clinical experience at TGH.
Students: Must have Hepatitis B vaccine or sign a
release if declining the vaccine. Required to get a
Tampa General Hospital badge from the Hospital HR
Department at the start of their clinical experience.
Badge must be worn above the waist at all times
while on the TGH Campus and returned to the HR
87
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Department at the end of their clinical experience.
USA/Faculty: Provide Program Description to facility.
Facility Contact: Annita Clark annita.clark@tananachiefs.org-907-452-8251, ext.
3704.
Student: Must have a criminal background check
under the Indian Child Protection Act (IPCA) through
the facility.
Tanana Chiefs Conference
Fairbanks, Alaska
MSN, DNP
Tanner Medical Center, Inc.
Carrollton, Georgia
Nursing
USA/Faculty: Provide names of students to agency.
Student: Criminal background check completed
within 12 months prior to clinical experience. Current
physical exam and drug screen. Fingernails and
artificial nails: Direct caregivers and food/nutrition
service workers will not be permitted to wear
artificial/acrylic fingernails or extenders. Keep natural
nail tips less than 1/4-inch long.
Tenet Health System GB, Inc. (dba
Atlanta Medical Center)
Atlanta, Georgia
Nursing
Administration
Tenet Health System dba Spalding
Regional Hospital
Griffin, Georgia
NP
Student attachments required prior to starting
clinicals. Please request Exhibit A and B from
faculty. Faculty may be required to validate students
completion of exhibit A & B. Faculty may be required
to sign Exhibit E.
USA Faculty: Complete and submit Exhibit C.
TCH Pediatric Associates, Inc. d/b/a
Texas Children’s Pediatric
Associates
Houston, Texas
Tennessee Valley Healthcare
System (All-Sites)
Nashville, Tennessee
Terry Reilly Health Services
Nampa, Idaho
Students: Complete and sign Exhibits A & B.
Students must have training in compliance with
OSHA. Students must view videotape regarding
Hospital's patient information, privacy policies and
practices in its entirety and have a passing score.
Video to be provided by Hospital. Students must
secure health insurance coverage.
MSN
BSN, RN-BSN,
MSN, DNP
USA/Faculty: Must submit to agency a minimum of
four weeks prior to the beginning of clinical a
schedule indicating the number and names of
students, name of preceptor and USA faculty. Copy
of student’s immunization records must be provided
to agency.
Student: Must complete the State of Idaho
Department of Health and Welfare criminal
background check prior to beginning of clinicals.
Texas Children’s Hospital
Houston, Texas
Advanced Practice
Texas Health Harris Methodist
Hospital Southwest Fort Worth and
Dr. Minh Q. Nghi
Advanced Practice
Student: Must carry and maintain health care
insurance. Must sign a confidentiality
agreement prior to clinicals, provided by
agency. Must complete any orientation/training
required by agency.
NOTE:
Agreement only covers Dr. Nghi as preceptor.
88
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
USA/Faculty: Provide to Facility at least two weeks
prior to clinicals, a letter outlining the needs of
students, days and hours students will be on patient
units or service areas, names of students and
supervising faculty members, length and dates of
clinical experience, and Texas nursing registration
numbers of on-site faculty.
Fort Worth, Texas
Student: Must be tested annually for tuberculosis. If
working in the laboratory, students must have
documentation that Meningococcal vaccine has
been administered.
USA/Faculty: Agency contact-Stephanie Stewartstephaniestewart@texashealth.org-214-860-6508.
Provide Faculty contact name and contact
information to facility. Provide Letter to Facility at
least 2 weeks prior to clinical, outlining the needs of
students, days and hours students will be on patient
units, names of students and supervising faculty
members, length and dates of clinical experience
and Texas nursing registration numbers or
credentials of on-site faculty.
Texas Health Physicians Group
Dallas, Texas
Student: Must be tested within one year of
commencement of Program and tested at least
annually while participating in the Program. Provide
evidence of such testing. Upon Facility's request
student will submit to a drug test and agree to have
the results made available to Facility. Must complete
Exhibit A-Student Confidentiality Agreement.
Texas Health Resources
Arlington, Texas
MSN
MSN Students Only
Please see Exhibit A for covered agency’s.
USA/Faculty: Confirm students have been instructed
in Standard Precautions recommended by the CDC.
Provide two weeks prior to beginning of clinicals, a
letter outlining the needs of students, days and hours
students will be on patient units or service areas,
names of students and supervising faculty members,
length and dates of clinical experience. Agency
Contact: Kesha Jackson, Education Coordinator682-236-6187-chekeshajackson@texashealth.org.
Students: Must complete Exhibit C-Confidentiality
Agreement. Must be aware of the Employee Health
policies and procedures of Facility.
Faculty: Agency requests student specific statement
of liability letter be sent to them (contact the USA
Contracts Office)
The Baton Rouge Clinic, AMC
Baton Rouge, Louisiana
Faculty must verify annually that the student has :
TB skin Test (annually)
Up to date Immunization History
Criminal Background check for the past 7 years
including Residency History
Nationwide Database with Sex Offender Index and
Healthcare Fraud & Abuse
Social Security Alert
Urine Drug Screen
Faculty, please ask Contract Office for
Credential/Administrative Sheet.
89
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
USA/Faculty: Submit in writing to agency the name
and academic credentials of person responsible for
the clinical education program, number of students,
dates, and length of clinical (agency contact info:
Christina Diekman - 513-585-2154
christina.diekman@thechristhospital.com).
Student: Must complete the Confidentiality and Data
Security Agreement. Must have coverage under a
policy of health insurance. Complete Exhibit A Confidentiality and Data Security.
The Christ Hospital
Cincinnati, Ohio
The Diabetes Center
Ocean Springs, Mississippi
The Heart Hospital Baylor Plano
Plano, Texas
BSN, RN-BSN,
MSN, DNP
DNP
For Preceptor Kathleen Arnold-please find her CV
and current License Verification under agency
attachments.
USA/Faculty: See Exhibit A for clinical
requirements. Provide requested information at
least 10 days prior to clinical experience.
Student: READ THOROUGHLY and complete
Exhibit B.
Student must carry their own occurrence-type
general l liability insurance coverage in
amounts not less than $1,000,000 per
occurrence and $3,000,000 annual aggregate.
USA/Faculty: Provide facility with an updated
copy of the program curricula and objectives.
Student: Shall provide their own identification
tags and uniform.
The Medical Center, Inc. (formerly
Columbus Regional)
Columbus, Georgia
The Queen’s Medical Center
Honolulu, Hawaii
The Toledo Hospital
Toledo, Ohio
The University of Texas Medical
Branch at Galveston (UTMB Health)
Galveston, Texas
MSN
The Villages Health
The Villages, Florida
The Woman’s Hospital of Texas
Houston, Texas
The Women’s Hospital (Deaconess)
Newburgh, IN
ThedaCare, Inc.
Appleton, Wisconsin
BSN, RN-BSN,
MSN, DNP
Provide names of students assigned to facility to
UTMB Contact: Kathy Angel 832-505-1026kangel@utmb.edu
MSN, DNP
BSN, MSN, DNP
RN-BSN, MSN,
DNP
USA/Faculty: Complete Agency's Attestation-Exhibit
C.
Student: Must complete Exhibits A & B.
USA/Faculty: Provide Influenza vaccination status
upon request.
USA/Faculty: Provide timely and accurate
information to Facility regarding the Program,
including the specific goals and objectives of
curriculum. Completed final placement form from the
school, validating the student has met the preplacement requirements on our student
site: http://www.fvhca.org/Graduate.html.Only submit
the Student/Faculty request form in Excel format, to
studentclinical@thedacare.org Must keep record of
completed Background Information Disclosure (BID)
forms on file with USA. Do not send to agency.
Student: Must have a caregiver background check in
accordance with the Wisconsin Caregiver
Background Check statutes (Wis. Stats. 48.685 and
50.065). Must obtain and maintain health insurance
coverage.
90
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Thibodaux Regional Medical Center
Thibodaux, Louisiana
Thomas Hospital
Fairhope, Alabama
Touro Infirmary
New Orleans, Louisiana
Touro Infirmary/Crescent City
Physicians
New Orleans, Louisiana
Triad of Alabama, LLC d/b/a
Flowers Hospital
Dothan, Alabama
Tripler Army Medical Center
Honolulu, Hawaii
Trinity Hospital of Augusta
MSN, DNP
MSN, DNP
Student: Must complete student orientation. Adhere
to the rules and regulations of the agency's Code of
Conduct and Ethics manual. See agency for copy.
USA Faculty and Students-Please see the
Standards of Conduct.
FNP, NNP
Faculty must complete Exhibit A. Student must
complete Exhibit B prior to clinicals.
FNP, NNP
FNP & NNP Students-Only 2 students per clinical.
USA Faculty must provide agency with student name
and course objectives and course outline prior to
clinicals. Student must have a satisfactory physical
examination within the past six (6) months with
medical clearance that includes; Hepatitis B titers,
titers for Rubella, Rubeola, Mumps and Varicella and
an TB test within the past six (6) months or bi-annual
chest x-ray. If the Hepatitis B titer is negative or nonreactive, then the Learning Institution must provide
proof of the Student’s vaccine that was received
after the titer and provide a new titer a month after
the receipt of the vaccine. The titer levels for
Rubeola, Mumps, and Varicella must be greater then
1.10. If the titer levels are not greater then 1.10, the
Learning Institution must provide proof of the
Student’s vaccine that was received after the titer
and provide a new titer a month after the receipt of
the vaccine. The titer level for Rubella must be
greater then 15. If not, the Learning Institution must
provide proof of the Student’s vaccine that was
received after the titer and provide a new titer a
month after the receipt of the vaccine. Student must
have flu shot during flu season by December 15th of
each year or they will be required to wear a mask.
Student must complete Exhibit B prior to clinicals.
Faculty shall review Addendum 1 & 2 with student
prior to student clinical rotation. Student must
complete and sign Addendums 4-5.
MSN, DNP
MSN, DNP
(renewal request sent, set to expire
8/14/2016)
Augusta, Georgia
TriStar Horizon Medical Center
Dickson, Tennessee
USA/Faculty: POI - Christi Callahanchristi.callahan@thibodaux.com. Background check
must be available to agency during a 24 hour notice
during the work week. Adhere to the rules and
regulations of the agency's Code of Conduct and
Ethics manual, if applicable.
Advanced
Emergency NP
91
USA/Faculty: Educate Students regarding OSHA
blood borne pathogens standards and tuberculosis
prior to clinicals.
Student: Please see Addendum 1-5. Must have a
negative TB skin test within the past year or if a
positive TB skin test a chest x-ray within the past 3
years. Completed series of Hepatitis-B vaccine, or
informed refusal of the vaccine.
USA/Faculty: See Exhibit A-Background Check
Requirements-Background Check must be
completed within a 90 day period immediately prior
to student's clinical placement.
Students: Complete Exhibits B-C and Authorization
for Release.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Tri Star Skyline Medical Center & Tri
Star Skyline Madison Campus
Nashville, Tennessee
Trover Foundation/Trover Health
Services (Expired-agency will renew
upon student request)
Madisonville, Kentucky
Tuba City Regional Health Care
Corporation
Tuba City, Arizona
Tucson Medical Center
Tucson, Arizona
MSN, DNP
Students shall pass a medical examination
acceptable to Hospital prior to their beginning their
clinical program and at least once a year or as
required by Tennessee law.
Students will present their health records on the first
day of clinicals, to include (TB skin test with in the
past 12 months or documentation as a previous
positive reactor, Proof of Rubella and Rebeola
immunity or 2 doses of MMR, Varicella immunity by
positive history of chickenpox or proof of
immunization, Proof of Heatitis B immunization or
declination of vaccine, if patient contact is
anticipated.
Student will need to provide proof of background
check. Please find exhibits A & B to be completed by
the student
Students must provide copies of all immunization
records to the site Clinical Education coordinator.
MSN, DNP
Agency Contact: Carolee Nelson-Clinical Services
Department-928-283-2588carolee.nelson@tchealth.org
USA/Faculty: Provide a letter of good standing to
facility at least 4 weeks prior to clinical start date.
Student: Must complete entry packet to include
fingerprinting, available from USA Faculty, at least
90 days in advance of clinical start date. as a
condition of placement at TCRHCC, each student
shall provide a written statement that s/he is not
currently suspended, excluded, debarred, or
otherwise ineligible to participate in the Federal
health care programs as defined in 42 U.S.C.
§1320a-7b(f) (the “Federal health care programs”);
(ii) are not convicted of a criminal offense related to
the provision of health care items or services but has
not yet been excluded, debarred or otherwise
declared ineligible to participate in the Federal health
care programs, and (iii) are not under investigation or
otherwise aware of any circumstances which may
result in the Educational Institution or a student
being excluded from participation in the Federal
health care programs, that student will immediately
notify TCRHCC of any investigation, exclusion or
loss of eligibility, and that student understands that
exclusion from participation in Medicare or any
federal health care program will result in the
termination of student’s participation in this program.
Faculty and Students, please see the Prevention and
Detection of Fraud, Waste and Abuse Policy and the
Vendor Life Safety Fact Sheet.
Nurse Practitioner
Program
Contact: Vicki Kelm, Student Placement Coordinator
vicki.kelm@tmcaz.com.
USA/Faculty: Provide Hospital with identification of
assigned students and the desired rotational
schedule for students.
Students: Must comply with Hospital’s Corporate
Compliance Program.
92
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Tulsa City-County Health
Department
Tulsa, Oklahoma
MSN, DNP
Twin Cities Hospital
Niceville, Florida
MSN, DNP
Students: Provide documentation required by facility
showing proof of any applicable vaccinations and/or
physical examination. Provide documentation
student have completed a background check and
drug screening within the previous six months.
U
UC Health (to include The Drake
Center and West Chester Hospital)
and University of Cincinnati
Physcians Company, LLC
Union Hospital, Inc.
Terre Haute, Indiana
MSN, DNP
MSN, DNP
Student must complete and sign Exhibit A Confidentiality Agreement.
Acute-Care Medical Surgical Facility
Faculty: Complete the Certform as directed
(available in the attachments file). Submit
documentation of completion to USA Clinical
Affairs Department.
Student: Complete Exhibits A & B. Must pass a
physical exam prior to clinical at least once a
year. Must obtain National Criminal
Background Check to include:
SS Number verification
Limited Criminal History (7 years or up to 5
criminal searches)
Violent Sexual Offender and Predator Registry
Search
Fingerprinting for those students and on-site
faculty who will be assigned to the Union
Hospital Child Care Center.
HHA/OIG List of Excluded Individuals
GSA List of Parties Excluded from Federal
Programs
US Treasury, Office of Foreign Assets Control
Must complete mandatory orientation at facility.
If bloodborne pathogen exposure occurs to
student they will be treated at the Health Office
form 7am-4pm. After 4pm, student is to notify
Administrative House Supervisor immediately.
UnityPoint Health-St. Luke’s
Sioux City, Iowa
United HealthCare Services, Inc.
d/b/a Evercare Georgia,
Norcross, Georgia
University Community Hospital d/b/a
Florida Hospital Tampa
Graduate Nursing
Students must complete attachments prior to
clinicals-See faculty
MSN, DNP
93
Students must assume responsibility for and
maintain health insurance.
Provide agency with documentation of their
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Tampa, Florida
criminal background check and immunizations.
University Health Services, Inc.
Augusta, Georgia
USA/Faculty: Certify that student participating in
onsite clinical training will have had criminal
background checks and urine drug screens
performed annually.
Student: Must have annual background check and
urine drug screen. Must sign a written agreement
(provided by facility) to observe all rules and policies
established by Facility, to maintain confidentiality of
patient information. At the option of the Facility,
health examinations may be performed by the
Facility, at the sole expense of the student
participant.
University Hospital and Clinics
Lafayette, Louisiana
University Medical Center Corp. and
University Physicians
Tucson, Arizona
*Now Banner Health agreement also
covers: University Medical Center
Corp. and University Physicians
Tucson, Arizona*
University of Alabama- Birmingham
Hospitals
Birmingham, Alabama
University of Alabama College of
Community Health Sciences (UMC)
Tuscaloosa, Alabama
University of Arkansas (University of
Arkansas for Medical Sciences)
Little Rock, Arkansas
University of California San
Francisco Medical Center
San Francisco, California
MSN, DNP
MSN, DNP
USA faculty please complete exhibit A. Students
may be required to show proof of health insurance.
BSN, RN-BSN,
MSN, DNP
MSN, DNP
MSN, DNP
USA/Faculty: Submit prior to clinical experience, a
student profile for each student (to include; student
name, address and telephone number, level of
academic preparation, length and dates of
experience) to Agency.
Student: Attend orientation to be provided by the
Clinical Facility. Must be covered by health
insurance.
University of Chicago Medical
Center
Chicago, Illinois (includes Comer
Children’s Hospital)
University of Colorado Hospital
Aurora, Colorado
BSN, RN-BSN,
MSN, DNP
Faculty must provide a written description of the
program and objectives of the courses and the
approximate number of students to be assigned at
any given time in the units. The names of the
students shall be submitted three weeks prior to the
beginning of the semester. USA must provide the
names and credentials of the faculty who will
participate in the Program activities.
MSN, DNP
Student must read and complete the Student
Health Screen Process documentation.
Student must fulfill Attachment A prior to
beginning clinicals Student must fulfill what is
94
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
outlined in Attachment A prior to beginning
clinicals
Faculty and Students: Please send the
following documentation to Kathy Foss ;
Katherine.foss@uch.edu:
Name of student in the clinical experience and
anticipated dates .
Proof of student’s health insurance
Letter of assurance regarding student’s health
status, confirming all immunizations, including
TB testing are up to date.
Current CPR card
Copy of objectives for clinical experience
Completion of UCH’s online orientation
program.
University of Florida, College of
Medicine
Jacksonville, Florida
University Health System
San Antonio, Texas
NP
MSN, DNP
Students must complete Exhibit A prior to beginning
clinicals. This includes a 12 panel drug screen.
Students will be responsible for purchasing
additional insurance through the UF Self-Insurance
Program at a fee of $100. per rotation. Payment is
due prior to the rotation start date and must be in the
form of a check payable to UF Self Insurance
Program.
*LON DOES NOT REQUIRE AGENCY OFFICIAL
SIGNATURE*
USA/Faculty: Please see Exhibit 1 for agency
requirements, forms must be submitted at least 2
weeks prior to beginning of clinical. NOTE: These
forms are to be completed by faculty not students.
University Health System, Inc.
(University of Tennessee)
Knoxville, Tennessee
University of Iowa Hospitals and
Clinics
Iowa City, Iowa
University of Kentucky Medical
Center
Lexington, Kentucky
University of Maryland Medical
Center
Baltimore, Maryland
University of Michigan Health
System
RN-BSN, MSN,
DNP
RN-BSN, MSN,
DNP
Student: Must have basic health insurance
coverage. Must attend Health System Orientation.
Please see Exhibits A& B and Influenza Form.
USA/Faculty: Submit in writing request for placement
at least 60 days in advance of first expected day of
clinical experience. Agency Contact: Dr. Lou Ann
Montgomery-Director, Nursing Professional
Development & Advanced Practice-loumontgomery@uiowa.edu-319-356-3959.
Student: Must maintain health insurance coverage
(for all health sciences students with clinical
exposures as part of their training). Training should
be no more than 3-12 hour shifts in a row without a
24 hour period of time off.
MSN ,DNP
BSN, MSN, NP
MSN, DNP
95
Students must contact Pat Imerman to set up their
clinicals.
859-257-9196 or p.imerman@uky.edu.
Student must complete Attachment A prior to
beginning clinicals.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Ann Arbor, Michigan
University of Minnesota Physicians
Minneapolis, Minnesota
MSN, DNP
(Minnesota sites should only
be utilized by approved USA
students)
University of Mississippi Medical
Center and all of UMMC’s Clinics
Jackson, Mississippi
BSN, RN-BSN,
MSN, DNP
NOTE: This is Faculty driven, not Clinical Affairs.
*AGENCY REQUIRES THIS 4 WEEKS PRIOR TO
CLINICAL.
Please find information pertaining to UMMC’s
Affiliated Student Process at the following link:
https://www.umc.edu/Education/Affiliated_Students.aspx
Please note: The affiliated student spreadsheet
MUST be submitted at least 4 weeks prior to the
start of the rotation. Complete only the blue portion
of the affiliated student spreadsheet; the green
portion of the spreadsheet is for UMMC use only. Be
sure that each student/instructor’s information is
complete before submitting the form (the full SSN
must be included).Be sure that all student/instructor’s
meet the
requirements found in the Affiliated Student OnBoarding Checklist.
The UMMC Affiliated Student Coordinator for your
area can be found at the following link, please feel
free to contact them with your questions/concerns.
Nursing Instructors Adrienne S. Murray
ASMurray@umc.edu
Nurse Practitioner Derek Holt
DHolt@umc.edu
Students must complete Epic System Training. Visit
affiliated student webpage www.umc.edu, click on
Education tab, then affiliated students under
Resources.
Students must complete Epic System Training.
Visit affiliated student webpage www.umc.edu, and
then click on Education tab, then affiliated students
under Resources.
University of Missouri Health Care
Columbia, Missouri
MSN, DNP
USA/Faculty: Complete Attachments 1 & 2 and
return to facility (fax number listed on
attachment) prior to beginning of student’s
clinicals.
Student: Complete Attachment 3Confidentiality Agreement. Upon Facility’s
request provide evidence of Hepatitis B
vaccine or a signed statement declining
Hepatitis B vaccine.
University of New Mexico Hospital
MSN, DNP
Agency requires student(s) be complete drug
screening within 6 months before beginning clinicals
96
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Albuquerque, New Mexico
University of New Mexico-Sandoval
Regional Medical Center
MSN, DNP
(renewal request sent, set to expire
8/1/2016)
Rio Rancho, New Mexico
University of North Carolina Hospital
(UNC Hospital)
Chapel Hill, North Carolina
BSN, RN-BSN,
MSN, DNP
University of North Carolina Chapel Hill School of Nursing
Chapel Hill, North Carolina
at UNMH. Faculty to complete Exhibit A. Student(s)
must provide UNMH and USA CON with copy of
certificate of insurance as proof of their property
damage coverage. USA/Faculty: Must complete the
Request for Placement form.
Student must submit an application for a Criminal
History Screening to the NM DOH (New Mexico
Dept. of Health) in accordance with the NM
Caregivers Criminal history Screening Act. Must
complete the CYFD Clearance Application. NM
CYFD Contact. Mary Gutierrez 505-827-9952
mary.gutierrez1@state.nm.us
USA/Faculty: Complete Exhibit A and email to
(Becky Josh) RCJosh@srmc.unm.edu at least seven
days in advance of clinicals.
Students: Must have received OSHA training in
blood-borne pathogens.
Faculty must provide number of student(s), course
objectives, and responsible faculty member from
USA to UNC’s program coordinator. Faculty and
Student please read Appendix A. Students must
read and sign Appendix B and C prior to beginning
clinicals. 12 panel drug screens required.
USA/Faculty - submit a schedule and list of students
at least fourteen days prior to clinicals. Submit
Appendices A-E, current clinical objectives, system
for reporting student performance and attendance,
evaluation forms. Must provide exposure control plan
and guidelines in accordance with OSHA Standards
for Blood borne Pathogens and TB. USA will provide
a copy of its exposure control plan and guidelines to
facility upon request. Must notify facility of within ten
days prior to clinical if student has criminal record.
Student - must obtain and maintain health insurance.
Must participate in any orientation/training required
and provided by facility. Criminal background check
must be completed within six calendar months from
the date the student begins clinicals.
University of North Carolina
Pembroke
Pembroke, North Carolina
University of Oklahoma, School of
Community Medicine
Tulsa, Oklahoma
BSN, RN-BSN,
MSN, DNP
University of South Alabama
Hospitals (to include the USA
Student Health Center, and CWH)
Mobile, Alabama
University of South Alabama
Mitchell Cancer Institute
Mobile, Alabama
University of Texas Health Science
BSN, RN-BSN,
MSN, DNP
MSN, DNP
USA/Faculty: Notify agency of the number of
students and the rotation periods in advance of
students' arrival. Agency contact: Mattie Lewismadison-lewis@ouhsc.edu.
Student: Must complete the Confidentiality
Agreement for agency.
BSN, RN-BSN,
MSN, DNP
MSN, DNP
97
Department of Pediatrics Only-Must complete a
program agreement for additional programs.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Center at Houston
Houston, Texas
USA/Faculty: Prior to the beginning of clinical
provide facility with names of the student, level of
academic preparation, length and dates of clinical to
Anthony Garcia-Dept of Pediatrics
anthony.l.garcia@uth.tmc.edu.
USA must (if applicable) ensure that each Student
has secured and maintains all documentation
required for Student to enter and stay in the US.
University of Texas MD Anderson
Cancer Center
Houston, Texas
University of Texas Southwestern
Dallas, Texas
MSN, DNP
MSN, DNP
USA/Faculty: Complete Agency’s Attestation
(available in Sakai).Provide the names and
schedules of the student participating in the clinical
experience. Provide verification upon request that
each student has complied with the following
screening under facility's policy (10 panel urine drug
screen, lab tests for (mumps, rubella, varicella,
rubeola, and hepatitis B titers with positive titers),
and immunizations including influenza and OSHA
requirements.
Student: Complete the below online training
modules, information for these modules will be
provided by facility's coordinator.
Information Security and Health Insurance
Portability and Accountability Act. Background check
must include the last seven years of employment.
University of Utah Hospitals and
Clinics
Salt Lake City, Utah
MSN, DNP
Student will be responsible for health
insurance.
University of Virginia Medical Center
and Transitional Care Hospital
Charlottesville, Virginia
Upson Regional Medical Center
Thomaston, Georgia
Upson Surgical Associates, LLC
Thomaston, Georgia
US Army Medical Department
Activity-Alaska
Ft. Wainwright, Alaska
US Naval Hospital
(renewal request sent, set to expire
Nursing and Nurse
Practitioner Programs
Faculty: At least four weeks prior to the
beginning date the agency must be sent the
name of each student, student info
(immunizations, background check, etc.) and
the program description to the University of
Utah Hospitals and Clinics. USA must provide
an explanation of the health and safety
standards set by OSHA and other applicable
law. Provide HIPAA training. Facility contact:
Milton Burbidgemilton.burbidge@hsc.utah.edu or Eddie
Decker-eddie.decker@hsc.utah.edu 801-2133491.
USA/Faculty: Provide to Agency roster of names of
the students, along with a rotation schedule to
agency sixty (60) days before clinical begins. Also,
provide Agency with clinical learning objectives,
schedules and assignments.
BSN, RN-BSN,
MSN, DNP
BSN, RN-BSN,
MSN, DNP
MSN, DNP
BSN, RN-BSN, RNMSN
98
USA/Faculty: Submit at least 30 days in advance of
clinical the names of students, dates and hours of
each training period and the clinical activities in
which training is being requested. Agency contact:
Captain Teresa Williamsteresa.a.williams104mil@mail.mil-907-361-5867.
Student must sign Trainee Agreement
Addendum
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
8/1/2016)
Naples, Italy
US Naval Hospital
Okinawa, Japan
US Naval Hospital
Yokosuka, Japan
MSN, DNP
Nursing
Student must sign Trainee Agreement
Addendum
Student must complete Trainee Agreement
Addendum
V
Valley Care Clinics and
Heart Clinics
Edinburg, Texas
Valley Health system, LLC (
RN-BSN, MSN,
DNP
MSN, DNP
USA Faculty must notify hospital of planned clinical training
experience, area, date of arrival, name of student. Provide a copy
of the performance objectives for the Training Experience. Consult
with Hospital’s Rep. for the student evaluation process. Student
must have training in blood and bodily fluid standard precautions
consistent with the US Centers for Disease Control and
Prevention Guidelines and provide certificate to hospital. Student
must have background check to include statewide criminal search,
civil and criminal public filings for the State of Nevada. Student
must submit the background check via PRE-CHECK to the
hospital prior to beginning clinicals. Student must sign Exhibit A
and B. Student must provide certificate of flu vaccination each
year they are in clinicals.
MSN, DNP
USA/Faculty: Must request student placement at agency in
writing (to include: type of unit, number of students, names
of students, desired dates and time of placement, including
days of week and hours to be on units) at least 90 days
prior to the start of rotation. See Exhibit A-C.
to include: Centennial Hills
Hospital, Spring Valley Hospital
Medical Center, Valley Health
Center, Desert Springs Hospital &
Valley Hospital Medical Center,
Summerlin Hospital Medical
Center, LLC)
(renewal request sent, set to
expire 6/30/2016)
Las Vegas, Nevada
Vanderbilt University
Medical Center (Hospital,
Clinic, Children’s Hospital)
Nashville, Tennessee
(Renewal request sent, set to
expire 7/31/2016)
Students please see agency contract specialist regarding
special instructions/attachments required before clinicals.
Students must obtain health insurance coverage.
Please note: this agreement
does not cover West End
Women's Health, which is
Vanderbilt School of Nursing
Clinic.
Variety Children’s Hospital,
Inc. d/b/a Nicklaus
Children’s Hospital
Miami, Florida
BSN, RN-BSN,
MSN, DNP
Students must register and complete all of the required
information at: http://www.mch.com/page/EN/44/ForMedical-Professionals/For-Students.aspx. Students are
required to submit their paperwork on line ten (10) days prior to
the beginning of clinicals. All information can be sent to Aida
Panciera (aida.panciera@mch.com).
USA must provide MCH with a signed Attestation of Student
Screening for each student, not less than ten (10) days prior to
the beginning of clinicals.
USA and Student must meet the requirements in the MCH student
99
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
orientation package. Available at
http://www.mch.com/page/EN/5162/ForStudents/Student-Orientation-Packages-.aspx. This will
include the student obtaining Level 2 fingerprinting, if applicable.
Vaughan Regional Medical
Center
Selma, Alabama
VA Medical Center (W.G.
(Bill) Hefner)
Salisbury, North Carolina
VA Central Iowa Health
Care System
Knoxville and Des Moines
Divisions
Veterans Affairs Gulf Coast
Healthcare System
Biloxi, Mississippi
Faculty must complete the Clinical Education, Clinical Instructor,
and Request for use of Clinical Facilities forms. prior to the
student beginning clinicals
CNL
BSN, MSN,
GRADUATE
CNL students only
Nursing: BSN, MSN, and graduate students
Agency requires Trainee Qualifications and Credentials
Verification Letter (TQCVL) signed by Program Director.
Students must go to the VA Gulf Coast in Biloxi to “Process
In” this includes fingerprinting 7-120 days prior to rotation,
once that is complete must return there to be issued their
Badge. Students must send copy of completed paperwork to
Sonya Ramsey - sonya.ramsey@va.gov.
VA Healthcare Center of
Bay Pines
Bay Pines, Florida
VA Hospital Denver
Denver, Colorado
VA Maryland Health Care
System
Baltimore, Maryland
VA Medical Center of
Alexandria, LA
Alexandria, Louisiana
VA Medical Center of Ann
Arbor
Ann Arbor, Michigan
VA Medical Center of
Asheville, NC
Asheville, North Carolina
VA Medical Center of
Atlanta
Atlanta, Georgia
BSN, MSN, DNP
MSN-FNP
GAPNP, BSN,
MSN
Faculty: Agency may request a Clinical Instructor Profile form
filled out. USA FACULTY- Please read the Trainee Process and
make sure students are aware of each step.
USA/Faculty: Letter of Agreement required for each program, to
be submitted by the Clinical Affairs Office prior to students clinical.
BSN, MSN, DNP
USA Faculty: Complete TQCVL form.
Student must contact agency to be fingerprinted 1 month prior to
rotation. Student cannot begin until results are back.
MSN-FNP ONLY
USA/Faculty: Please complete Attestation and TQCVL
documents.
Gerontological/Adult Psychiatric NP (On-Line) Bachelor and
Master
MSN
Nursing Program, Master’s
Advanced
Practive
Advanced Practice Nursing
MSN, Geron. NP,
RN-BSN, MSN,
DNP
100
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
VA Medical Center of
Birmingham
Birmingham, Alabama
VA Medical Center of Carl
Vinson
Dublin, Georgia
VA Medical Center of
Charlie Norwood
Augusta, Georgia
VA Medical Center of
Cheyenne
Cheyenne, WY
VA Medical Center of
Cincinnati Ohio
Cincinnati, Ohio
VA Medical Center of
Fayetteville
Fayetteville, North Carolina
VA Medical Center of Grand
Junction
Grand Junction, Colorado
VA Medical Center of
Huntington
Huntington, West Virginia
VA Medical Center - G.V.
(Sonny) Montgomery
Jackson, Mississippi
VA Medical Center of
Marion, IL
Marion, Illinois
BSN-MSN
BSN-MSN
MSN, NP
NP: Masters Program
MSN-GNP, DNP
BSN, RN-BSN,
MSN, DNP
BSN, MSN, DNP
NP
Nursing (MSN-GNP Degree Programs)
DNP Students
Nursing/Nurse Practitioner/MS
BSN and Graduate Nursing Students
Nurse Practitioner
MSN
MSN students
MSN
Occupational Therapy – MS
Nursing-Adult Geron Acute and Primary including Primary Care
Nursing – Acute NP (Masters)
Nursing – Geri Psych NP (Masters)
Nursing – Family NP (Masters)
Nursing – BSN
Nursing – MSN
Masters-ENP Program
Clinical Nurse Leader (MSN)
Master of Science
Call 618-997-5311 ext. 54013 to schedule fingerprinting
appointment
Attached is the paperwork that needs to be completed prior to
starting your rotation at the Marion VAMC. As soon as it is
complete, you will need to contact Human Resources to set-up an
appointment to get fingerprinted and to turn in your paperwork.
Please remember you must be fingerprinted at least 1 month
before your rotation begins. Please print and complete all
attachments and call 618-997-5311 ext. 54013, Kim Turk, to
schedule a fingerprint appointment & to turn in your paperwork.
Bring completed forms with you the day of your appointment. If
you have specific questions related to the forms please contact
Tammy Cesar-Sargent (contact information below). Human
Resources is your contact for scheduling fingerprinting
appointments and questions regarding the paperwork
Attached are instructions, on how to log on to the Talent
Management System (TMS) website to complete the mandatory
education module. You are only required to complete the
101
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Mandatory Training for Trainees. If any other items show up on
your “To-Do List” please ignore them. Please print out a
completion certificate for your records and give to your preceptoryou do not have to turn in a certificate to me. Any questions
related to the education modules, please contact Christine
Stearns (contact information below).
I have also attached an instruction page regarding our Learner’s
Perception survey. Please log onto the website on your last day
and complete the survey – it only takes 10 minutes. This is the
only feedback we receive about your rotation!
If you are here less than 15 days you can use your student ID
badge as your ID badge while at the facility. If you are here for
longer you will need to receive a VA issued ID badge.
Lastly, we need verification that you have received a TB test
within the last year and received a negative result. Please turn in
this information with the rest of your paperwork. Please keep in
mind that you must be fingerprinted at least 1 month prior to your
first clinical rotation day, no exceptions. Your preceptor will be
notified when your fingerprints have cleared and you are eligible
to start your internship/rotation
All of this information is also available on the Marion VAMC
homepage:
http://www.marion.va.gov/careers/Clinical_Training_Internship.asp
VA Medical Center of
Memphis, TN
Memphis, Tennessee
VA Medical Center of
Michael DeBakey Center
Houston, Texas
BSN and MSN
VA Medical Center of New
Mexico
Albuquerque, New Mexico
BSN, MSN
VA Medical Center of New
Orleans
New Orleans, Louisiana
VA Medical Center of
Northhampton, MA
Leeds, Massachusetts
VA Medical Center of
Northport, NY
Northport, New York
VA Medical Center
Oklahoma City
MSN
Master of Science
Graduate
Graduate Degree
BSN, MSN, NP
Nursing Baccalaureate Degree,
Masters Degree NP
MSN Students.
(Renewal request sent, set to
expire 7/31/2016)
Oklahoma City, Oklahoma
VA Medical Center of
Overton Brooks
BSN, RN-BSN,
MSN, DNP
Undergraduate & Graduate degrees in Science of Nursing
TQCVL Paperwork in agency attachment folder. Graduate
102
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Shreveport, Louisiana
VA Medical Center of
Portland, OR
Portland, Oregon
GERON
/ADULT
PSYCHIATRIC,
MSN
VA Medical Center of Salem
Salem, Virginia
ADVANCED
EMERGENCY
NP
VA Medical Center of St.
Louis, MO
St. Louis, Missouri
VA Medical Center of
Tuscaloosa, Alabama
Tuscaloosa, Alabama
VA Medical Center (Wm.
Jennings Dorn)
Columbia, South Carolina
Faculty: Students and their perspective sites must be
approved by the Oregon Board of Nursing through USA’s
Contract Office. USA Faculty must have a Oregon APRN
license.
Advanced Emergency NP’s only. Faculty, please complete the
TQCVL form. Students must complete the VA FORM10 and the
Student Application.
BSN, MSN, DNP
MSN-Family
Psych Only
VA North Texas Medical
Center
Dallas, Texas
AGPNP, RNBSN-MSN, MSN,
VA North Florida/South
Georgia Health System
Gainesville, Florida
RN-BSN/BSN,
MSN
VA Northern California
Health Care System
Mather, CA
VA Outpatient Clinic
Chattanooga, Tennessee
VA Pacific Islands Health
Care System
Honolulu, Hawaii
VA Phoenix Healthcare
System
Phoenix, Arizona
VA Puget Sound Health
Care System
Seattle, Washington
VA Roseburg Healthcare
System
Degree. USA Faculty please ask Dr. Rhodes to sign the TQCVL
form.
Gerontological/Adult Psychiatric, Masters
Faculty-Educational Institution Verification Letter must be signed
and sent from USA CON, Associate Dean for Academic Affairs to:
Wm. Jennings Dorn VA Hospital
Attn: Tom Wiseman
Administrative Officer-Education (141)
6439 Garners Ferry Road
Columbia, SC 29209
Advanced Geropsych Assessment Older Adults Practicum RNBSN-MSN
Master of Science in Nursing
Brenda.ingram@va.gov 214-857-0768. Student’s need about 6-8
weeks to “clear” before coming to the VA. VA fingerprint and
process with H R. It will take at least 30 days from fingerprinting
to “clear”.
RN-BSN/BSN & MSN Please see attachments from agency.
Faculty and Students please allow 6-8 weeks for processing time.
BSN, MSN, DNP
Graduate, MSN
MSN
Graduate Program,
Master of Science in Nursing
MSN students only
USA Faculty, please complete the Education Program Letter of
Agreement for each student and return to: Amanda Morrowamanda.morrow@va.gov-541-440-1000 x 44225.
103
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Roseburg, Oregon
VA Sierra Nevada Health
Care System
Reno, Nevada
VA Stars and Stripes
Healthcare Network
Lebanon, Pennsylvania
Ventura County Behavioral
Health
Oxnard, California
Vidant Health (to include: Vidant
MC, Vidant Beaufort Hospital, Vidant
Bertie Hospital, Vidant Chowan
Hospital, Vidant Duplin Hospital,
Vidant Edgecombe Hospital,
SurgiCenter of Eastern Carolina, Outer
Banks Hospital, Vidant Roanoke
Chowan Hospital, Vidant Home Health
& Hospice, Vidant Medical Group)
MSN, DNP
BSN, RN-BSN,
RN-MSN
Greenville, North Carolina
Virginia Commonwealth
University Health System
Agency requesting to update
agreement.
(Medical College of Virginia)
Richmond, Virginia
Virginia Mason Medical
Center
Seattle, Washington
USA/Faculty: Coordinate with Hospital and ensure the
performance of duties and responsibilities placed by Hospital's
Infection Control Policies. Submit in writing the names of each
faculty member, faculty members' credentials, and contact
information. Provide the Hospital with copies of current course
outlines, course objectives, curriculum philosophy, and student
evaluation forms pertaining to clinicals. Extend Hospital
appropriate personnel adjunct appointments on the Schools
teaching faculty where feasible and applicable.
Students: Provide Hospital with copy of current immunization
records. Complete Appendix A. Complete an acknowledgement of
understanding of the policies provided by the agency.
RN-BSN, MSN,
DNP
Covers: RN-BSN, MSN, and DNP Students
USA/Faculty: Must provide student names, and relevant
education and training at least four (4) weeks prior to
clinicals (if less than 4 weeks, by fax immediately). Assure
student is trained in blood borne pathogens.
Student: Student is responsible for supplying any
additional information required by facility prior to their
arrival. May be required to submit the facility's
Contractor/Student Fitness for Duty Compliance
Certification forms (provided by facility). Must obtain
liability insurance in the amounts set forth by the facility,
$1,000,000 per occurrence and $5,000.000 in annual
aggregate ( as this amount is more than the University's
coverage) and provide a valid certificate of insurance upon
request by facility.
Virtua Health, Inc. (includes:
Virtua-West Jersey Health
and Virtua-Memorial
Hospital Burlington County)
Marlton, New Jersey
Graduate
USA/Faculty: Provide certification that the student is in good
health.
Students: Must meet the OSHA requirements regarding Hepatitis
B. The Facility may, upon request, require that any student
returning from an absence caused by illness and or injury submit
a physician's statement of good health.
104
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
W
For Clinical Faculty and Students additional onsite requirements may include participating in
orientation, on site HIPAA and other training,
submission to a TB test, submission of a
criminal background check, a 10 panel drug
screen, and proof of a seasonal flu vaccine.
Please see Exhibits A-E
Wake Forest University Baptist
Medical Center (North Carolina
Baptist Hospital)
Winston-Salem, North Carolina
Walla Walla General Hospital
Walla Walla, Washington
Walter Reed National Military
Medical Center
Bethesda. Maryland
Walton County Health Department
Defuniak Springs, Florida
Washington Regional Medical
Center
Fayetteville, Arkansas
RN-BSN, MSN,
DNP
WellPoint, Inc. (CareMore Health)
Indianapolis, Indiana
WellSpan Health
York, Pennsylvania
AGACNP
WellStar Health System, Inc. (to
include: Cobb, Kennestone,
Paulding, Douglas, and Windy Hill)
Marietta, Georgia
BSN, MSN, DSN,
RN-MSN, DNP
Wesley Medical Center
Hattiesburg, Mississippi
West Central Georgia Regional
Hospital
Students must complete the Training Affiliation
Agreement Addendum.
MSN, DNP
MSN, DNP
DNP
BSN, RN-BSN,
MSN, DNP
MSN, DNP
(renewal request sent, set to expire
6/30/2016)
Columbus, Georgia
105
USA/Faculty: Provide copy of course outlines and/or
clinical objectives for a specific clinical rotation.
Provide a list of names of students and faculty
directing the learning experiences of each semester
in experience.
Student: Must complete a urine drug screen
test. Must present to facility within 7 days of
commencement of their experience a copy of
negative urine drug screen. Must provide a copy of
criminal background check for the state in which the
student resides.
Faculty must send Education Verification Letter to
agency prior to beginning of clinicals.
Six weeks prior to clinical Faculty must submit to
agency the following: student list, dates, hours for
clinicals, level of experience, learning objectives, and
names of students.
USA Faculty, please see agency instruction letter.
Only WellStar employees are eligible. Students must
complete an orientation packet prior to beginning
any clinical rotation.
Faculty, please complete the organizational Learning
form for each semester for each program at a Well
Star facility (form available in the attachments
folder).
“Student Agreement Only”-Students should
complete a Term Sheet from the agency Now
includes FNP students. Agency contact is Terry
Trigg Tel: (601) 268-8058.
USA/Faculty: Terms of start/end dates must be
agreed upon with agency at least one month
prior to clinicals. If student has an exposure to
blood/body substances, if there is an injury, to
student or if there is an infectious disease
outbreak, USA agrees to send student's health
records within two business days of the written
request by facility for such health records.
Students: May be required to sign a written
agreement obligating student to observe all
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
rules and policies of facility and maintain
confidentiality of all patient and facility
information. May be required to sign Release
of Information. Must have current health
examination.
West Florida Hospital
Pensacola, Florida
West Georgia Health
LaGrange, Georgia
West Virginia University, School of
Medicine and West Virginia
University Hospital
Morgantown, West Virginia
West Virginia University, University
Healthcare, University Healthcare
Physicians
Morgantown, West Virginia
Western State Hospital—DSHS
Mental Health Division
Olympia, Washington
Wheaton Franciscan HealthcareSoutheast Wisconsin, Inc.
Milwaukee, Wisconsin
White-Wilson Medical Center, P.A.
Fort Walton Beach, Florida
William Beaumont Army Medical
Center
El Paso, Texas
William S. Middleton Memorial
Veteran’s Hospital
Madison, Wisconsin
Willis-Knighton Health System (sites
MSN, DNP
RN-BSN, MSN,
DNP
MSN, DNP
Graduate Nursing
USA/Faculty: Complete Exhibit C-Attestation of
Background Investigation/Drug Screen
Students: Complete Exhibit A and B.
Students: Must undergo a complete physical
examination (less than 1 year old), background
check, and drug screening prior to clinicals.
Student: May be required to provide documentation
of a satisfactory physical or health report and proof
of such immunizations as facility may reasonably
require.
USA/Faculty: Notify Agency of student name,
respective level of academic preparation, length and
dates of clinical experience. Provide (if requested)
description of the curriculum.
USA/Faculty: May be required to submit the following
information to facility: beginning and end dates of
clinical, number of students, specific days, hours,
and locations, learning objectives, performance
expectations for students, deadlines and format of
the progress report and/or evaluation forms. Must
provide curriculum and the professional and
academic credentials of its faculty for the students.
MSN, DNP
APRN
FNP
MSN, DNP
available in Louisiana, Arkansas and
Texas)
Shreveport, Louisiana
106
Student: Must have yearly PPD TB testing or followup if student is ppd-positive. Must have background
record from the Washington State Patrol and provide
to facility.
Students and Faculty please see ALL detailed
requirements. Faculty, please see agency
attachments within PUB DOCs.
Student: Provide proof of OSHA and HIPAA
education to facility. Maintain individual health and
accident insurance while in the performance of
agreement.
Family Nurse Practitioner students
(Agreement applies to only one trainee at a time).
Student is responsible for their own personal health
care expenses.
Student must have a Fit Test for the N95 Respirator
and is responsible for the cost of test.
Students please see Flu Shot Memo and Declination
of Seasonal Influenza Vaccine.
Students must register within the agency's database
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
-complete orientation packet and return all
documentation to agency 21 days prior to clinical
rotation (please see attachment).
Women & Infants Hospital
Providence, Rhode Island
Graduate
USA/Faculty: Provide a schedule to Hospital 2-3
months prior to the start of the semester. Provide
attestation that lists students, completion of health
screening requirements (See attachment).
Student: Must complete Hospital Mandatory
Orientation and/or comparable skill sets prior to their
initial contact with Hospital. Must have current
physical examination. A color blindness test may be
administered when applicable to job function.
Women’s Hospital
Baton Rouge, Louisiana
Women’s Health Care of Western
Colorado, P.C.
Grand Junction, Colorado
Womack Army Medical Center
Ft. Bragg, North Carolina
BSN, RN-BSN,
MSN, DNP
Wuesthoff Medical
Center/Rockledge
Rockledge, Florida
RN-BSN, MSN,
DNP
Student: Complete Addenda 4 & 5. Must have
received education regarding clinical safety,
including OSHA blood borne pathogens standards,
and tuberculosis transmission prevention prior to
clinical rotation. Must provide Florida RN Primary
source verification of the current license.
NP
USA Faculty please note: Written Objectives for
agency’s review and comment may be requested.
Keep agency informed of hours and arrange for
agency to evaluate student’s performance. Students
must read and sign Exhibit B.
BSN, RN-BSN,
MSN, DNP
MSN, DNP
For MSN and DNP – No more than three (3) trainees
annually. Faculty must contact Ms. Tanya Sinclair
at 910-907-8625 tanya.s.sinclair.civ@mail.mil 30
days in advance for each student placement. Ms.
Sinclair is the point of contact for correspondence
from NP track faculty who send emails to verify proof
of clinical site approval by faculty and/or information
regarding our contact information.
X
XLHome, P.C. and XLHome
Northeast, P.C.
Elkridge, Maryland
Y
107
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Z
Zablocki VA Medical Center
Milwaukee, Wisconsin
108