UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Alabama
Alabama Department of Public
Health, (Alabama inclusive)
Alabama Department of
Rehabilitation Services
Mobile, Alabama
AltaPointe Health Systems, Inc.
(formerly Mobile Mental Health and
Baldwin Mental Health)
BSN, RN-BSN, MSN,
DNP
BSN, RN-BSN, MSN,
DNP
BSN, RN-BSN, MSN,
DNP
Please note the contact person for clinicals are as
follows:
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
American Family Care, Inc.
Birmingham, Alabama
Andalusia Regional Hospital
Andalusia, Alabama
Anniston Pediatrics, Inc.
Anniston, Alabama
Baldwin County Public Schools
Fairhope, Alabama
BSN, RN-BSN, MSN,
DNP
BSN, RN-BSN, MSN,
DNP
BSN, RN-BSN, MSN,
DNP
BSN, RN-BSN, MSN,
DNP
Baptist Health System (covers-
BSN, RN-BSN, MSN,
DNP
Princeton, Shelby, Walker and Citizen’s)
Birmingham, Alabama
Baptist Medical Center South
(includes Baptist Medical Center
East and Prattville Baptist
Hospital)
Montgomery, Alabama
Beverly Healthcare
Foley, Alabama
Brookwood Health Services, Inc.
Birmingham, Alabama
BSN, RN-BSN, MSN,
DNP
BSN, RN-BSN, MSN,
DNP
BSN, MSN, DNP
1
Faculty must notify school prior to clinical
experience
Agency Education Contact: Vicki Hill-205-7837067-vicki.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
in HIPAA requirements and OSHA regulations.
See attachment A-Competency Validation Policy
Clinical Instructors and Students.
Students must complete required training before
beginning training. Student may be required to sign
an individual agreement with agency.
BSN students: Request Attachments A-C prior to
clinical. They are Statement of Responsibility,
Confidentially Statement, and Background
Screening Attestation.
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
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Brookwood Physician Practices,
LLC (covers Cahaba Heights,
Homewood, Hoover, Narrows,
Oak Mountain, Vestavia,
Inverness, Greystone Internal
Medicine)
Birmingham, Alabama
Cathedral Place Apartments
Mobile, Alabama
Central Plaza Towers
Mobile, Alabama
Children’s Hospital of Alabama
Birmingham, Alabama
Children’s Rehab Services
Mobile, Alabama
Christian Medical Ministry of
South Alabama
Mobile, AL
Cullman Regional Medical
Center
Cullman, Alabama
DCH Hospital Authority (includes
Nursing
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.
BSN, MSN, DNP
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.
NP
BSN, RN-BSN, MSN,
DNP
Undergraduate
RN-BSN, MSN, DNP
RN, RN-BSN, MSN, DNP
BSN, RN-BSN, MSN, DNP
Fayette Medical Center, Northport
Medical Center)
Tuscaloosa, Alabama
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.
E.A. Roberts Alzheimer’s Center
Mobile, Alabama
East Alabama Medical Center
and EAMC Lanier
Valley, Alabama
Eliza Coffee Memorial and
Shoals Hospital
BSN, RN-BSN, MSN,
DNP
Nursing
2
Students: Complete Exhibit A & B.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Florence, Alabama
Escambia County Alabama
Community Hospitals, Inc., d/b/a
Atmore Community Hospital
(Infirmary Health)
Mobile, Alabama
Fox Army Health Center
Redstone Arsenal, Alabama
Franklin Primary Health Center,
Inc.
Mobile, Alabama
Gadsden Regional Primary
Care, LLC
MSN, DNP
Nursing-Not NP’s
(renewal request sent, set to expire
8/24/2016)
Gadsden, Alabama
Gordon Oaks Health and Rehab
Mobile, Alabama
Grandview Medical Group
Birmingham, Alabama
Greenville Clinic Corp.
Greenville, Alabama
Healthsouth Rehab Corporation
Mobile, Alabama
Housing First, Inc. (15th Place)
Mobile, Alabama
Huntsville Hospital (to include:
Huntsville Hospital (main),
Huntsville Hospital for Women &
Children, Madison Hospital,
Parkway Medical Center, Heart
Center, Inc. and Athens-Limestone
Hospital)
BSN, RN-BSN, MSN,
DNP
Nurse Practitioner
RN-BSN, MSN, DNP
MSN, DNP
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 OB-GYN
Associates, P.C., IMC Pediatrics and
USA/Faculty: See Addenda 1 & 2 for Patient Care
Duties provided.
Students: Must complete Addenda 3, 4 and 7.
Students: Complete Addenda 4 & 5. Must have
health insurance during clinical experience at
Facility.
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
substances immediately prior to student beginning
clinicals.
Huntsville, Alabama
IMC Clinics (to include: IMC Baldwin
USA Faculty please see Addena 1-3.
Students must complete Addendum 4Substance Policy Consent Form and Addendum
5- Background Consent Form.
BSN, RN-BSN, MSN,
DNP
3
Huntsville Hospital's Emergency Department will
not be accepting clinical or precepting requests for
Fall 2014 or Spring 2015.
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
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.
Mobile, Alabama
InPatient Consultants of
Alabama, Inc. (in conjunction with
BSN, RN-BSN, MSN,
DNP
the following: Springhill Medical Center,
Mobile Infirmary Medical Center, and
North Baldwin Infirmary)
North Hollywood, CA
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.
Laurel Oaks Behavioral Health
Center
Dothan, Alabama
Lyster U.S. Army Health Clinic
Fort Rucker, Alabama
Marengo Family Health Center
Demopolis, Alabama
Marshall Medical Centers
Guntersville, Alabama
Medical Center Enterprise
Enterprise, Alabama
RN, RN-BSN, MSN, DNP
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
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 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 4.See Addendum 5 regarding
Background Consent Form.
Students: Complete Addendum 4 & 5.
4
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Mobile County Health
Department
Mobile, Alabama
Mobile County Public Schools
Mobile, Alabama
Mobile Infirmary Association d/b/a
Mobile Infirmary Medical Center
BSN, RN-BSN, MSN,
DNP
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 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
North Baldwin Infirmary
Bay Minette, Alabama
Northeast Alabama Regional
Medical Center
Anniston, Alabama
BSN, RN-BSN, MSN,
DNP
BSN, RN-BSN, MSN,
DNP
USA Faculty and Students-Please see the
Standards of Conduct.
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.
BSN, RN-BSN, MSN,
DNP
Student: Must complete facility’s orientation and
acknowledgment sheet through agency and return
to agency’s Human Resources prior to clinicals.
Northport Medical Center (DCH
Hospital Authority)
Northport, Alabama
Providence Hospital
Mobile, Alabama
BSN, RN-BSN, MSN,
DNP
BSN, RN-BSN, MSN,
DNP
5
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
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
vaccination history of measles and rubella.
Documentation of most recent Tetanus Toxoid
injection.
Documentation of annual Bloodborne Pathogen
training from University or in the alternative to
require students to attend agency’s training
session.
Students must complete departmental orientation to
specific Bloodblorne Pathogen issues.
Saad’s Health Care
Mobile, Alabama
Seton Medical Management
Mobile, Alabama
South Baldwin Regional Medical
Center
Foley, Alabama
BSN, RNBSN, MSN, DNP
BSN, RN-BSN, MSN,
DNP
BSN, RN-BSN, MSN,
DNP
Southeast Alabama Medical
Center
Dothan, Alabama
Springhill Memorial Hospital
Mobile, Alabama
BSN, RN-BSN, MSN,
DNP
St. Vincent’s Health System
Birmingham, Alabama
Thomas Hospital
Fairhope, Alabama
Triad of Alabama, LLC d/b/a
Flowers Hospital
Dothan, Alabama
University of Alabama Birmingham Hospitals
Birmingham, Alabama
University of Alabama College of
Community Health Sciences
(UMC)
Tuscaloosa, Alabama
University of South Alabama
Hospitals (to include the USA
Student Health Center and
CWH)
Mobile, Alabama
BSN, RN-BSN, MSN,
DNP
BSN, RN-BSN, MSN,
DNP
MSN, DNP
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).
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.
Please see required additional documents per the
agreement. Contact: Kelly Bachus - (205) 930-2744
(office)- Kelly.Bachus@stvhs.com
USA Faculty and Students- Please see the
Standards of Conduct.
Faculty shall review Addendum 1 & 2 with student
prior to student clinical rotation. Student must
complete and sign Addendums 4-5.
BSN, RN-BSN, MSN,
DNP
BSN, RN-BSN, MSN,
DNP
6
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
USA Mitchell Cancer Institute
Mobile, Alabama
Central Alabama Veterans
Healthcare System
Montgomery and Tuskegee
Alabama
VA Medical Center of
Birmingham
Birmingham, Alabama
VA Medical Center of
Tuscaloosa, AL
Tuscaloosa, Alabama
Vaughan Regional Medical
Center
Selma, Alabama
BSN, MSN
BSN and MSN
BSN- MSN
BSN-MSN
BSN, MSN and DNP
BSN, RN-BSN, MSN,
DNP
Alaska
673rd Medical Group, Join Base,
Elmendorf-Richardson
JBER, Alaska
Alaska Regional Hospital
RN-BSN, MSN, DNP
MSN, DNP
USA/Faculty: Verify and complete AttestationExhibit 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
Facility any change in student’s status. Provide
opportunity to receive Hepatitis B vaccine to clinical
students.
Anchorage, Alaska
Alaska Tribal Health
Consortium/Alaska Native
Medical Center
Anchorage, Alaska
Attachment 1 and 2 for Trainee Agreement
Addendum
Nursing
7
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
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.
Providence Health & Services –
Washington d/b/a Providence
Health & Services Alaska
Region
Anchorage, Alaska
MSN, DNP
Tanana Chiefs Conference
Fairbanks, Alaska
MSN, DNP
US Army Medical Department
Activity-Alaska
Ft. Wainwright, Alaska
MSN, DNP
Non-employees must complete an Alaska
background check orientation prior to beginning
clinicals.
Faculty must provide agency with a list of students
before they begin clinicals. Student Rotations
Coordinator: Amanda Patterson
Amanda.Patterson@providence.org (907) 2126580.
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.
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.
Arizona
Apogee Medical Management,
Inc.
Phoenix, Arizona
Advanced Practice Nursing
Banner Health
Phoenix, Arizona
*Now Banner Health agreement
also covers: University Medical
Center Corp. and University
Physicians
Tucson, Arizona*
Students: Must maintain health insurance during
clinicals. Must have education in OSHA/Blood
Borne Pathogens and HIPAA regulations prior to
clinicals.
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.
Faculty and Students, please refer to Exhibit AHealth Standards (available from the contract
office). Students must comply with OSHA
guidelines and training. If students’ 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 a consent for release
8
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
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 a consent of release.
BH shall conduct a background investigation on
(on-site) 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 days prior to Rotation.
Faculty must notify BH of any student placed on the
Sanctions list by the Department of Health and
Human Services.
Carondelet Health Network
Tuscon, Arizona
RN-BSN, MSN, DNP
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).
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
Honor Health (Scottsdale
Healthcare)
Scottsdale, Arizona
Mountain States Neonatology,
Inc.
Phoenix, AZ
Northern Arizona Healthcare (to
include: Flagstaff Medical
Center, Verde Valley Medical
Center, and Northern Arizona
Homecare)
Flagstaff, Arizona
Phoenix Children’s Hospital, Inc.
Phoenix, Arizona
MSN, DNP
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.
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.
Student must complete Attachments B & C prior to
beginning clinicals.
NP
9
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Tuba City Regional Health Care
Corporation
Tuba City, Arizona
Tucson Medical Center
Tucson, Arizona
MSN, DNP
Nurse Practitioner Program
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.
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.
University Medical Center Corp.
and University Physicians
Tucson, Arizona *Now covered by
MSN, DNP
Students: Must comply with Hospital’s Corporate
Compliance Program.
USA faculty please complete exhibit A. Students
may be required to show proof of health insurance.
Banner Health Agreement*
VA Phoenix Healthcare System
Phoenix, Arizona
Arkansas ***
Arkansas Children’s Hospital
Little Rock, Arkansas
Baptist Health Medical Center-
Faculty must provide facility official with
students’ names, dates, and hours of
assignment and level of care by students.
Nursing
10
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
North Little Rock
Little Rock, Arkansas
Baxter Regional Medical Center
Mountain Home, Arkansas
BSN, RN-BSN, MSN,
DNP
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.
Central Arkansas Veterans
Healthcare System
Little Rock, Arkansas
CHI St. Vincent Hot Springs
Hot Springs, Arkansas
BSN, RN-BSN, MSN,
DNP
BSN, RN-BSN, RN-MSN, MSN, and DNP
BSN, RN-BSN, MSN,
DNP
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.
Fort Smith HMA, LLC d/b/a
Sparks Health System
Fort Smith, Arkansas
Mercy Health System of
Northwest Arkansas
Rogers, Arkansas
Mercy Hospital Fort Smith
MSN, DNP
MSN
BSN, RN-BSN, MSN,
11
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.
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.
Students: Should obtain and maintain health
insurance. Must provide documentation of criminal
background check.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Fort Smith, Arkansas
Northwest Arkansas Hospitals,
LLC ( to include; Northwest
Medical Center-Springdale,
Northwest Medical CenterBentonville, Willow Creek
Women’s Hospital
Johnson, Arkansas
Northwest Physicians, LLCBenton County Physician
Services
Springdale, Arkansas
DNP
Saline Memorial Hospital
Benton, Arkansas
St. Mary’s Physician Services,
LLC d/b/a Millard Henry Clinic
Russellville, Arkansas
BSN, RN-BSN, MSN,
DNP
St. Vincent Infirmary Medical
Center
Little Rock, Arkansas
University of Arkansas
(University of Arkansas for
Medical Sciences (UAMS)
Little Rock, Arkansas
Washington Regional Medical
Center
Fayetteville, Arkansas
MSN, DNP
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.
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.
ADVANCED FAMILY
PRACTICE NP
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.
Students must complete Exhibit A prior to beginning
clinicals.
MSN, DNP
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.
California
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
City of Hope National Medical
Center
Duarte, California
12
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
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.
Community Medical Centers
Fresno (to include: Community
Regional Medical Center, Clovis
Community Medical Center,
Fresno Heart and Surgical
Hospital)
APRN
Doctors Medical Center of
Modesto
Modesto, California
Hany S. Aziz, MD, Inc.
Bakersfield, California
InPatient Consultants of Florida,
Inc.
North Hollywood, California
(Main Ofc.)
BSN, RN-BSN, RNMSN and NP
Kaiser Foundation Hospitals and
the Permanente Medical Group,
Inc., California
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 Venkatesanjvenkatesan@communitymedical.org.
Student: Must have Attachment A and Exhibit A
completed.
MSN, DNP
MSN, DNP
USA/Faculty: Obtain from each facility, acceptance
and acknowledgment of the students participation in
the clinical experience. Provide student information
(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.
Student: Must obtain and maintain health insurance
coverage. Must complete and sign Exhibit BStudent Agreement.
Contact Information:
NP
Toni Groth-toni.groth@kp.org
Cheryl Kenner-cheryl.a.kenner@kp.org (Roseville
site only)
13
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Jackie Lewis-jacqueline.m.lewis@kp.org
HOSPITALS
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, Fresno, Richmond, Gilroy,
Roseville, Martinez, San Jose, Novato,
Stockton, Napa, Vacaville, Milpitas
Lakewood Regional Medical
Center
MSN, DNP
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.
NP
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
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.
(renewal request sent, set to expire
8/1/2016)
Lakewood, California
Rady Children’s Hospital
San Diego, California
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.
Saddleback Memorial Medical
Center
Laguna Hills, California
DNP
14
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.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Students: Must maintain adequate healthcare
coverage. Must have received training in HIPPA
compliance and blood and body fluid standard
precautions consistent with the Center for Disease
Control guidelines. Also to complete any Facility
orientation requirements.
San Joaquin Community
Hospital
Bakersfield, California
BSN, RN-BSN, RNMSN
Santa Clara Valley Medical
Center and Santa Clara Valley
Health and Hospital System
San Jose, California
BSN, RN-BSN, RNMSN
Scripps Health (to include: Scripps
RN-BSN
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
Student’s drug screen results, background check,
and scheduling of students must be provided to the
agency within 60 days prior to the beginning of
clinicals.
Students must carry own health insurance.
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).
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.
RN-BSN Only
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 blood
borne 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
15
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Sharp HealthCare
San Diego, California
Nursing Informatics,
Family Psychiatric NP
NURSING INFORMATICS and FAMILY
PSYCHIATRIC NP PROGRAM ONLY
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.
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 student’s 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.
Silver Lake Medical Center
(Success Healthcare, LLC)
Los Angeles, CA
Stanford Health Care/ValleyCare
Pleasanton, California
University of California San
Francisco Medical Center
San Francisco, California
MSN, DNP
BSN, RN-BSN, 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.
VA Northern California Health
Care System
Mather, CA
Ventura County Behavioral
Health
Oxnard, California
BSN, MSN, DNP
MSN, DNP
Colorado
21st Medical Group, Peterson
Air Force Base
Executive Nursing Admin
DNP ONLY
16
Executive Nursing Admin DNP ONLY
Student must complete Attachment 1
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Colorado
Boulder Medical Center, P.C.
Boulder, Colorado
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)
Student must complete Exhibits A&B.
BSN, RN-BSN, RNMSN
Englewood, Colorado
Denver Health and Hospital
Authority
Denver, Colorado
Evans Army Community Hospital
Fort Carson, Colorado
InPatient Consultants of
Colorado, P.C.
MSN, DNP
MSN, DNP
MSN, DNP
17
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.
Term for each student must be agreed upon at
least (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,
check must be made payable to DHHA and must
be completed 10 days prior to clinicals. Students
must carry health insurance coverage under an
accident and sickness health insurance plan and
must bear the following wording in lieu of the
standard wording; “Should any of the above
described policies be canceled, the issuing
company will mail within 45 days a written notice by
Certified Mail to DHHA at 660 Bannock Street, 5th
floor, Mail Code 5015, Denver, CO 80204.”
Students must be 18 years or older.
USA must send names of students, dates & hours
requested 60 days prior to clinicals to agency.
USA/Faculty: Provide to Medical Group-list of
Students who will be in facility, dates and obtain
approval from Medical Group.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
North Hollywood, CA
National Jewish Health
Denver, Colorado
Parkview Medical Center
BSN, RN-BSN, MSN,
DNP
MSN
(renewal request sent, set to expire
6/30/2016)
Pueblo, Colorado
Students: Must complete Exhibit A-Student
Agreement. Must carry health insurance coverage
during clinicals at Medical Group.
See Exhibit A-Immunization requirements per the
agreement.
MSN Students Only
USA/Faculty: Provide agency with a letter
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.
Student: Must be current in there licensure.
Southwest Health System
Cortez, Colorado
MSN, DNP
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.
St. Mary’s Hospital & Medical
Center, Inc.
Grand Junction, Colorado
MSN, DNP
University of Colorado Hospital
MSN ,DNP
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.
Student must read and complete the Student
Health Screen Process documentation. Student
18
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Aurora, Colorado
VA Medical Center of Grand
Junction
Grand Junction, Colorado
VA Hospital Denver
Denver, Colorado
Women’s Health Care of
Western Colorado, P.C.
Grand Junction, Colorado
MSN
MSN-FNP
must fulfill Attachment A prior to beginning clinicals
Student must fulfill what is 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.
MSN students
MSN-FNP ONLY
USA/Faculty: Please complete Attestation and
TQCVL documents.
BSN, RN-BSN, MSN,
DNP
Connecticut
Connecticut Children’s Medical
Center
Hartford, Connecticut
Connecticut Mental Health
Affiliates, Inc.
Nursing
BSN, RN-BSN, MSN,
DNP
(renewal request sent, set to expire
6/6/2016)
New Britain, Connecticut
Naval Health Clinic New
England
Naval Branch Health Clinic
Groton
Groton, Connecticut
MSN, DNP
19
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.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Delaware
USA/Faculty: Please see required attachments in
Pub Docs.
Nemours-Alfred I. DuPont
Hospital for Children
Wilmington, Delaware
Florida
Access Community Health Care
Spring Hill, Florida
Azalea Health (Rural Health
Care, Inc.)
Palatka, Florida
Baker County Health
Department
Macclenny, Florida
Baptist Health Care Corporation
Pensacola, Florida
Includes: Baptist Hospital, Pensacola, FL
BSN, RN-BSN, MSN,
DNP
BSN, RN-BSN, MSN, DNP
BSN, RN-BSN, MSN,
DNP
BSN, MSN, DNP
Gulf Breeze Hospital, Gulf Breeze,
FL
Atmore Community Hospital,
Atmore, AL
Baptist Medical Group, Pace, FL
Baptist Health System-Florida
Jacksonville, Florida
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.
BSN, RN-BSN, MSN, DNP
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.
USA Faculty must sign and complete the
Attestation form and email to Barbara Hamiltonbarbara.hamiliton@bhcpns.org
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.
Faculty must complete Schedule A. Student must
complete the Student Agreement and
Baptist Hospital of Miami (to
include: Doctors Hospital, Inc.,
20
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Acknowledgement form. Faculty must have active
Florida license and CPR Certification. Please ask
for Section 9 School Certification forms.
Homestead Hospital, Inc., South
Miami Hospital, Inc., Mariners
Hospital, Inc., West Kendall Baptist
Hospital, Inc., and Baptist
Outpatient Services, Inc.,)
Florida Department of HealthBay County
Panama City, Florida
Nursing
Bay Medical Center –Sacred
Heart Health System
Panama City, Florida
BayCare Health System, Inc. (to
Nursing
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.)
BSN, RN-BSN, MSN,
DNP
APRN students must complete the “Physician
Sponsored Student Application”
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
Central Florida Healthcare, Inc.
Winter Haven, Florida
Children’s Med Services, Florida
Department of Health
Panama City, Florida
Citrus County Health
Department
Lecanto, Florida
Cleveland Clinic Florida
USA/Faculty: Complete Exhibit C-Attestation
Students: Complete Exhibits A & B.
BSN, RN-BSN, MSN, DNP
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.
Agency may put limit on amount of students per
semester.
RN-BSN, MSN, DNP
BSN, RN-BSN, MSN,
DNP
RN-BSN, MSN, DNP
21
USA/Faculty: Please see Protocol for Practicum
and Preceptorships. Please note and keep a record
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
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 AG, 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
Weston, Florida
are aware of the virus.
Columbia County-Florida
Department of Health
Lake City, Florida
Covenant Hospice
Pensacola, Florida
Doctors Hospital of Sarasota
Sarasota, Florida
BSN, RN-BSN, MSN,
DNP
RN-BSN, MSN, DNP
Eglin Air Force Base, 96th
Medical Group/SGSF
Eglin AFB, Florida
BSN, RN-BSN, MSN,
DNP
Emergency Physicians of
Central Florida, LLC
Orlando, Florida
Fawcett Memorial Hospital
Port Charlotte, Florida
Florida Department of HealthDuval County
Jacksonville, Florida
Florida Department of Health
Lee County
Fort Myers, Florida
BSN, RN-BSN, MSN,
DNP
RN-BSN, MSN, DNP
GRADUATE
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).
Student must have confidentiality statement signed
and witnessed. Flu vaccination (Nov.1st-March
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
see updated Student Intern Data Record.
USA/Faculty: Must complete Exhibit C-Attestation
Form.
Student: Must complete Exhibits A&B. Must pass
medical examination acceptable to Hospital.
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.
Student must complete the Confidentiality
Statement.
Student: Must complete Exhibits A-C. Must pass a
medical examination acceptable to Hospital.
Student must complete Attachment AConfidentiality Agreement and submit to Yvette
Andrews (yvette.andrews@flhealth.gov) prior to
clinicals.
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.
22
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Florida Department of HealthLevy County Health Department
Bronson, Florida
Florida Department of Health
Includes: Holmes County Health
Dept.
BSN, RN-BSN, MSN,
DNP
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).
BSN, RN-BSN, MSN,
DNP
(renewal request sent, set to expire
8/1/2016)
Bonifay, Florida
Florida Department of Health
Seminole County
Sanford, Florida
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 Hospital Fish Memorial
(SW Volusia Healthcare Corp.)
Orange City, Florida
Florida Hospital North Pinellas
Tarpon Springs, Florida
Nursing
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.
Student must take Compliance test from agency
prior to beginning clinical rotation. Also exhibits
must be completed.–Agency contact: Richelle
Kennedy, MSM, and 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
Gulf Coast Medical Center
Panama, City, Florida
Halifax Health
Daytona Beach, Florida
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.
BSN, RN-BSN, MSN,
DNP
Nurse Practitioner
23
Student must complete Exhibits A-C.
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
required by Facility.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Holmes County Department of
Health
Bonifay, Florida
Hope Hospice and Community
Services, Inc.
Fort Myers, Florida
InPhyNet Primary Care (3-way
agreement with Iberia Medical
Center)
Fort Lauderdale, Florida
InPhyNet Contracting Services,
LLC
Jackson Hospital
Marianna, Florida
James A. Haley Veteran’s
Hospital
Tampa, Florida
Lee Memorial Health System
(covers: LMHS Psychiatric
Consultation, Gulf Coast Medical
Center, Health Park Medical
Center, Cape Coral Medical
Center, and Lee Memorial
Hospital)
Cape Coral, Florida
Manatee Healthcare System and
Lakewood Ranch Medical
Center
Bradenton, Florida
Martin Memorial Health
Systems, Inc.
Stuart, Florida
Mayo Clinic Jacksonville
Jacksonville, Florida
BSN, RN-BSN, MSN,
DNP
MSN, DNP
NP
Nursing
Emergency Room Department Students – Iberia
Medical Center clinicals.
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.
BSN, MSN, DNP
DNP, CNL
BSN, RN-BSN, MSN,
DNP
MSN, DNP
Agency only accommodating DNP, and CNL,
Nursing Education, Administration and Informatics
at this time. 5/5/2014
USA/Faculty and Student: Complete Exhibit BStudent Attestation.
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.
MSN, DNP
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.
24
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Should you have any questions, please do not
hesitate to contact me. Any costs for the admission
requirements are the responsibility of the student.
Memorial Healthcare Group,
Inc./dba Memorial Hospital
Jacksonville, Florida
MSN, DNP
Munroe Regional Medical Center
Ocala, Florida
BSN, MSN, DNP
Naval Hospital (to include Its
Branch Clinics, i.e., Whiting Field
Clinic)
Pensacola, Florida
NCH Healthcare (Naples
Community Hospital)
RN-BSN, MSN, DNP
NP
(Renewal request sent, set to expire
7/31/2016)
USA/Faculty: Must complete Exhibits C-D.
Students: Must complete Exhibits A-B.
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.
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 X-Ray 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.
Contract includes: Allied Health students
Students are required to complete a confidentiality
statement prior to clinical experience (See faculty)
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.
Naples, Florida
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.
Nemours Foundation (includes
USA/Faculty: Please see required attachments in
25
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Children’s Clinic in Destin, FL)
Pensacola, Florida
North Okaloosa Medical Center
Crestview, Florida
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
Pub Docs.
NP
MSN, DNP
Undergraduate
Athletic Training
Students are required to participate in an hourly
rounding lab before clinicals at facility. NP students
only.
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.
Okaloosa County Health Dept.
Fort Walton Beach, Florida
Orange Park Medical Center
Orange Park, Florida
Palm Beach County Health
Department, Florida
West Palm Beach, Florida
Palm Beach Gardens
Community Hospital, Inc.
Palm Beach Gardens, Florida
Paragon Contracting Services,
LLC
Gables, Florida
BSN, RN-BSN, MSN,
DNP
RN-BSN, MSN, DNP Only.
USA Faculty cannot do site visits to this facility.
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.
Nursing
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).
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 SignatureParagon 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.
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
26
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Planned Parenthood of SW &
Central Florida
Sarasota, Florida
Premier Community Healthcare
Dade City, Florida
BSN, RN-BSN, MSN,
DNP
BSN, RN-BSN, MSN, DNP
USA/Faculty: See attached required
documentation. Agency contact: Christina
LaCross-CLaCross@hcnetwork.org. Submit
student details (year student, site interest,
subspecialty, hours, and dates) prior to any
other documentation.
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
Sacred Heart Health System
Pensacola, Florida
experience.
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 pre-placement 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
MSN, DNP
Santa Rosa Medical Center
Milton, Florida
NP
Santa Rosa Public Health
Department
Milton, Florida
Sarasota Memorial Health
System
Sarasota, Florida
NP
BSN, MSN, DNP
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: 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.
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
27
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
search, which may 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.
Select Specialty Hospital
Tallahassee, Florida
MSN, DNP
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.
Shands Jacksonville Medical
Center
Jacksonville, Florida
Shands Lake Shore Regional
Medical Center
Lake City, Florida
USA/Faculty: Please see student requirements.
Nurse Practitioner
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
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).
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
Shands Teaching Hospital and
Clinics d/b/a Shands at the
University of Florida (Shands at
Vista and Shands Rehab
Hospital)
Gainesville, Florida
Sheridan Children’s Healthcare
Services, Inc.
Plantation, Florida
28
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Sheridan Children’s Healthcare
Services and South Broward
Hospital District d/b/a Memorial
Healthcare System (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.
includes: Memorial Regional, Memorial
Regional Hospital South, Joe DiMaggio
Children’s Hospital, Memorial Hospital
Pembroke, Memorial Hospital West,
Memorial Hospital Miramar)
Hollywood, Florida
South Lake Hospital
Clermont, Florida
St. Vincent’s Health System (to
include: St. Vincent’s Medical
Center-Southside, St. Vincent’s
Medical Center-Clay County)
Jacksonville, Florida
St. Vincent’s Medical Center,
Inc.-Riverside
Jacksonville, Florida
Tallahassee Memorial
HealthCare, Inc.
BSN, RN-BSN, MSN,
DNP
GRADUATE
GRADUATE
NP
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 BConfidentiality Agreement.
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.
NP STUDENTS
Faculty may need to send clinical program letter to
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
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
29
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
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.
Tampa General Hospital (Florida
Health Science Center and
Florida Gulf to Bay) (Florida Gulf
MSN, Emergency NP,
Acute Care NP
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 Department at the end of their clinical
experience.
Contract only to be used as a 3-way agreement
with Tampa General/Gulf to Bay/University of South
Alabama
to Bay Anesthesiology Associates,
PA)
Tampa, Florida
Tampa General Hospital and
University of South Florida
Tampa, Florida
The Villages Health
The Villages, Florida
Twin Cities Hospital
Niceville, Florida
University Community Hospital
d/b/a Florida Hospital Tampa
Tampa, Florida
University of Florida, College of
Medicine
Jacksonville, Florida
VA Healthcare Center of Bay
Pines
Bay Pines, Florida
DNP
DNP Students
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.
BSN, RN-BSN, MSN,
DNP
MSN, DNP
MSN, DNP
NP
BSN, MSN, DNP
30
Students must assume responsibility for and
maintain health insurance.
Provide agency with documentation of their criminal
background check and immunizations.
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.
USA/Faculty: Letter of Agreement required for each
program, to be submitted by the Clinical Affairs
Office prior to students clinical.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
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.
North Florida/South Georgia VA
Health System
Gainesville, Florida
Variety Children’s Hospital, Inc.
d/b/a Nicklaus Children’s
Hospital
Miami, Florida
RN-BSN/BSN, MSN
BSN, RN-BSN, MSN, DNP
RN-BSN/BSN & MSN Please see attachments from
agency. Faculty and Students please allow 6-8
weeks for processing time.
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 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.
Walton County Health
Department
Defuniak Springs, Florida
West Florida Hospital
Pensacola, Florida
White-Wilson Medical Center,
P.A.
Fort Walton Beach, Florida
Wuesthoff Medical
Center/Rockledge
Rockledge, Florida
MSN, DNP
MSN, DNP
APRN
RN-BSN, MSN, DNP
USA/Faculty: Complete Exhibit C-Attestation of
Background Investigation/Drug Screen
Students: Complete Exhibit A and B.
Student: Provide proof of OSHA and HIPAA
education to facility. Maintain individual health and
accident insurance while in the performance of
agreement.
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.
Georgia
Adventist Health System
Georgia, Inc. d/b/a Gordon
Hospital
Albany Primary Health Care,
Inc.
RN-BSN, MSN, DNP
BSN, RN-BSN, MSN,
DNP
(renewal request sent, set to expire
6/14/2016)
31
Students may be required to undergo a health
examination.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Albany, Georgia
AllWell Behavioral, LLC
Warner Robins, Georgia
Athens Regional Health
Services, Inc.
Athens, Georgia
Children’s Healthcare of Atlanta
(covers Egleston and Scottish
Rite)
Atlanta, Georgia
Coliseum Medical Center
Macon, Georgia
Covington Women’s Health
Specialists, LLC
Covington, Georgia
Dekalb Medical Center
Decatur, Georgia
Floyd Healthcare Management
Rome, Georgia
Gentiva Hospice
Columbus, Georgia
Georgia Regents Medical Center
Augusta, Georgia
BSN, RN-BSN, MSN,
DNP
Nursing
BSN, RN-BSN, MSN,
DNP
USA/Faculty: Provide student and program
information to facility 15 days prior to clinicals facility student placement contact: Nicki Turner
706-475-3594 nturner@armc.org.
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.
Students must complete Exhibits A, B-1, and C
prior to clinical.
BSN, RN-BSN, MSN, DNP
BSN, RN-BSN, MSN,
DNP
RN-BSN, MSN, DNP, NP
Student: Must complete Hospital orientation.
RN-BSN, MSN, DNP
MSN, DNP
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.
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 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-
Georgia Regional Hospital at
Atlanta
Atlanta, Georgia
32
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
4752.
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
Grady Health System
Atlanta, Georgia
Gwinnett Hospital System, Inc.
Lawrenceville and Duluth,
Georgia
Gwinnett Hospital System, Inc.
Lawrenceville and Duluth,
Georgia
MSN, DNP
USA/Faculty and Students: Please see Exhibits BE, for review and completion. Students notify
faculty prior to starting clinicals. Please see Clinical
Orientation Instructions.
– preceptor Dr. Phillip Cannon only.
Please see website for placement information:
www.gwinnettmedicalcenter.org.
FNP Only
Gwinnett Hospital System, Inc.
Lawrenceville and Duluth,
Georgia
NP
Gwinnett Hospital System, Inc.
Lawrenceville, Georgia
BSN, MSN, DNP
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/program
NP students only – preceptor Dr. Leslie Leigh;
Students must review Exhibit “A” Permitted
Activities of the Student NNP students only –
preceptor Dr. Leslie Leigh;
Students must review Exhibit “A” Permitted
Activities of the Student
2013 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
Harbin Clinic
Rome, Georgia
HSOC, Inc. (Children at Hughes
Spaulding)
Atlanta, Georgia
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.
I.D. Group of Atlanta
33
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Atlanta, Georgia
Martin Army Community Hospital
Fort Benning, Georgia
Meadows Regional Medical
Center
Vidalia, Georgia
Medical Center of Central
Georgia
Macon, Georgia
Memorial Hospital University
Medical Center
Savannah, Georgia
North Fulton Women’s
Specialists & North Fulton
Hospital
Roswell, Georgia
Northside Hospital
Atlanta, Georgia
Phoebe Putney Health System
Albany, Georgia
Piedmont Healthcare, Inc.
(facilities covered by agreement:
BSN, GRADUATE
MSN, DNP
MSN, DNP
MSN, DNP
FNP
BSN, MSN, DNP
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 and Students: Please see the 2015
updated instructions and attachments for
requirements per the agreement.
Faculty please complete Exhibit B (Faculty
Agreement) and Exhibit G (Verification of Student
Information) Student must complete attachments C
through F.
Student must complete Exhibits A& B. Faculty to
complete Exhibit C.
Program must be approved by hospital prior to the
beginning of clinicals.
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 immunization). Student to
complete Exhibit B.
BSN, RN-BSN, MSN, DNP
MSN, DNP
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.
Fayette 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
Saint Lazarus Behavioral Health,
Inc.
Macon, Georgia
St. Joseph’s /Candler Health
System
Savannah, Georgia
BSN and graduate students
BSN, RN-BSN, MSN,
DNP
ACUTE CARE,
EMERGENCY, MSN
FAMILY, PEDIATRIC
NP
34
Covered programs are:
Acute Care NP
BSN
Emergency NP
MSN FNP
Pediatric NP
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Southeast Regional Primary
Care Corporation (to include Dublin
MSN, DNP
Internal Medicine and Vidalia Women’s
Center)
Vidalia, Georgia
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
St. Mary’s Health Care System
Athens, Georgia
Tanner Medical Center, Inc.
Carrollton, Georgia
Tenet Health System GB, Inc.
dba Atlanta Medical Center
Atlanta, Georgia
Tenet Health System dba
Spalding Regional Hospital
Griffin, Georgia
RN-BSN, MSN, DNP
Nursing
NURSING
ADMINISTRATION
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.
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.
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.
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, 706-389-2150,
klawrence@stmarysathens.org.
Student: Submit the Orientation packet
(provided by Agency) to Agency at least two
weeks prior to clinical.
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.
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.
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.
35
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Student must carry their own occurrencetype general liability insurance coverage in
amounts not less than $1,000,000 per
occurrence and $3,000,000 annual
aggregate.
The Medical Center, Inc.
(formerly Columbus Regional)
Columbus, Georgia
Trinity Hospital of Augusta
MSN, DNP
(renewal request sent, set to expire
8/1/2016)
Augusta, Georgia
United HealthCare Services, Inc.
d/b/a Evercare Georgia,
Norcross, Georgia
University Health Services, Inc.
Augusta, Georgia
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.
Students must complete attachments prior to
clinicals-See faculty
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.
Upson Regional Medical Center
Thomaston, Georgia
Upson Surgical Associates, LLC
Thomaston, Georgia
VA Medical Center of Atlanta
Atlanta, Georgia
VA Medical Center of Carl
Vinson
Dublin, Georgia
VA Medical Center of Charlie
Norwood
Augusta, Georgia
WellStar Health System, Inc. (to
include: Cobb, Kennestone,
Paulding, Douglas, and Windy
Hill)
Marietta, Georgia
BSN, RN-BSN, MSN,
DNP
BSN, RN-BSN, MSN,
DNP
MSN, Geron. NP, RNBSN-MSN, DNP
MSN, NP
West Central Georgia Regional
Hospital
MSN, DNP
MSN-GNP, DNP
BSN, MSN, DSN, RNMSN, DNP
(renewal request sent, set to expire
6/30/2016)
Columbus, Georgia
36
NP: Masters Program
Nursing (MSN-GNP Degree Programs)
DNP 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).
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
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
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 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 Georgia Health
LaGrange, Georgia
RN-BSN, MSN, DNP
Students: Must undergo a complete physical
examination (less than 1 year old), background
check, and drug screening prior to clinicals.
Hawaii
Hawaii Pacific Health
Honolulu, Hawaii
MSN, DNP
The Queen’s Medical Center
Honolulu, Hawaii
Tripler Army Medical Center
Honolulu, Hawaii
VA Pacific Islands Health Care
System
Honolulu, Hawaii
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/Faculty: Provide facility with an updated copy
of the program curricula and objectives.
Student: Shall provide their own identification tags
and uniform.
MSN ,DNP
MSN
MSN students only
Idaho
Boise VAMC
Boise, Idaho
Eastern Idaho Health Services
Idaho Falls, Idaho
Kootenai Health
Coeur d’Alene, Idaho
AGACNP
BSN, RN-BSN, MSN,
DNP
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.
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.
Saint Alphonsus Health System
MUST BE RESIDENTS OF
37
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
(to include: Nampa, Idaho and
Boise, Idaho)
Boise, Idaho
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
D-Student Agreement.
USA/Faculty: Please complete Exhibit BVerification of Required Documentation Statement,
two weeks prior to the beginning of clinicals.
Ensure students have received in compliance with
OSHA Blood-Borne Pathogen Regulations and
infection control procedures prior to clinical
experience.
St. Joseph Regional Medical
Center
Lewiston, Idaho
Student: Must complete Exhibit C-Student
Agreement-Clinical Experience.
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 (HaileyKetchum), 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
State Hospital South
Blackfoot, Idaho
Terry Reilly Health Services
Nampa, Idaho
MSN, NP, DNP
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
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.
BSN, RN-BSN, MSN,
DNP
BSN, RN-BSN, MSN,
DNP
38
Undergraduate and Graduate Students
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
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Department of Health and Welfare criminal
background check prior to beginning of clinicals.
Illinois
Access Community
Health Network
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.
Nursing
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.
(Renewal request sent, set to
expire 7/14/2016)
Chicago, IL (see Exhibit A
for complete lists of affiliates
covered by agreement)
CDH-Delnor Health
System (to 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
Edward Hospital
Elmhurst, Illinois
Linden Oaks Hospital
Naperville, Illinois
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)
RN-BSN, MSN, DNP
MSN, DNP
RN-BSN, MSN, DNP
RN-BSN, MSN,
RN-DNP
PLEASE SEE EXHIBIT C-Agency Requirements. Students must
obtain prior written approval of the Site prior before publishing any
material relating to clinical experience.
Student: Must maintain comprehensive health insurance. Obtain
prior written approval of the Facility before publishing any material
relating to the clinical experience.
Student must maintain comprehensive health insurance during
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 Blood borne Pathogens and
Tuberculosis.
39
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Springfield, Illinois
Northwestern Memorial
Hospital
Chicago, Illinois
Promise Healthcare
d/b/a Frances Nelson
Champaign, Illinois
Rush Oak Park
Hospital
Oak Park, Illinois
Rush University Medical
Center
Chicago, Illinois
Southern Illinois Hospital
Services (to include:
RN-BSN, MSN, DNP
RN-BSN, MSN,
RN-DNP
RN-BSN, MSN,
RN-DNP
GRADUATE
CNS
Memorial Hospital of
Carbondale, Herrin Hospital,
St. Joseph Memorial
Hospital)
Carbondale, Illinois
St. Mary’s Hospital
Decatur, Illinois
University of Chicago
Medical Center
Chicago, Illinois (includes
Comer Children’s
Hospital)
VA Medical Center of
Marion, IL
Marion, Illinois
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.
MSN, DNP, NP
RN-BSN, MSN,
RN-DNP
MSN
Faculty and Students please see Exhibit C for list of agency
requirements.
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 tes (step 2), chest xray 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, Illinoise) for preassignment testing. Failing the drug test will result in withdrawal of
clinical assignment for one year.
MSN, DNP, and NP Students
USA/Faculty: Agency Contact-Anita Ricker-anita.ricker@hshs.org217-464-1074. Please see Exhibit C-Program Requirements.
Student: Must have OSHA compliance for prevention of
transmission of blood borne pathogens and TB.
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.
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
40
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
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
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
Indiana
American Health Network of
Ohio, PC
Indianapolis, Indiana
Community Health Network (to
include: Community Hospital
North, Community Hospital East,
Community Hospital South, and
Community Home Health).
Indianapolis, Indiana
RN-BSN, MSN, RNDNP
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.
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-317-621-7973.
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-
41
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Deaconess Hospital, Inc.
Evansville, Indiana
Floyd Memorial Hospital and
Health Services
New Albany, Indiana
King’s Daughters’ Health
Madison, Indiana
Lutheran Hospital of Indiana
Fort Wayne, Indiana
Nursing
MSN, DNP
MSN, DNP
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. Must sign a confidentiality
agreement as provided and required by facility.
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.
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.
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.
St. Mary’s Health, Inc.
Evansville, Indiana
RN-BSN, MSN, DNP
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.
Union Hospital, Inc.
Terre Haute, Indiana
MSN, DNP
Acute-Care Medical Surgical Facility
Faculty: Complete the Certform as directed
42
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
(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.
WellPoint, Inc. (CareMore
Health)
Indianapolis, Indiana
AGACNP
Faculty must send Education Verification Letter to
agency prior to beginning of clinicals.
Iowa
Central Iowa Hospital, Corp.
d/b/a UnityPoint Health - Des
Moines
Des Moines, Iowa
Mercy Medical Center
Des Moines, Iowa
Planned Parenthood of the
Heartland
Des Moines, IA
The Women’s Hospital
(Deaconess)
Newburgh, IN
UnityPoint Health-St. Luke’s
Nursing
MSN, DNP
RN-BSN, MSN, DNP
BSN, MSN, DNP
Graduate Nursing
43
USA Faculty: Must give each student participating
in clinicals at facility a Student Orientation Manual.
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.
Exhibit A must be completed and signed by
student.
Contact:
Christine Jaynes Contreras
christine.jaynescontreras@ppheartland.org
USA/Faculty: Provide Influenza vaccination status
upon request.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Sioux City, Iowa
University of Iowa Hospitals and
Clinics
Iowa City, Iowa
VA Central Iowa Health Care
System
Knoxville and Des Moines
Divisions
RN-BSN, MSN, DNP
CNL
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-lou-montgomery@uiowa.edu-319-3563959.
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.
CNL students only
Kansas
* At this time students may not preform clinical experiences in this state.*
Kentucky
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.
Baptist Healthcare System, Inc.
d/b/a Baptist Health Lexington
Lexington, Kentucky
Baptist Health Madisonville, Inc.
Madisonville, Kentucky
Baptist Health System, Inc. d/b/a
Baptist Health Paducah
Paducah, Kentucky
NP
Student must sign Statement of Understanding and
Confidentiality Agreement.
RN-BSN, MSN, RNDNP
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.
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.
BSN, MSN, DNP
44
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Baptist Physicians Lexington,
Inc., d/b/a Baptist Internal
Medicine Group (Baptist Medical
Group)
Lexington, Kentucky
Blanchfield Army Community
Hospital
Fort Campbell, Kentucky
Commonwealth Health
Corporation
Bowling Green, Kentucky
Frankfort Regional Medical
Center
Frankfort, Kentucky
Graves Gilbert Clinic
Bowling Green, Kentucky
Jewish Hospital & St. Mary’s
Healthcare, Inc. d/b/a Jewish
Hospital
Louisville, Kentucky
Mercy Health Partners-Lourdes
Paducah, Kentucky
NP
USA Faculty must have a current, active,
unencumbered APRN license in state of practice.
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.
MSN, DNP
MSN, DNP
NP
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.
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.
RN-BSN, MSN,
DNP
MSN, DNP
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.
Nursing
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
45
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Norton Healthcare/ Neonatal
Associates
(Norton Kosair Children’s
Hospital, Norton Suburban
Hospital, Norton Audubon
Hospital, Norton Hospital, and
Norton Brownsboro Hospital)
Louisville, Kentucky
Norton Hospitals, Inc. (Norton
NP
MSN, DNP
Student: Must have negative drug screen within six
months of placement at Hospital.
RN-BSN, MSN, RNDNP
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: 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.
Audubon Hospital, Norton Brownsboro
Hospital, Norton Women’s & Kosair
Children’s Hospital, Kosair Children’s
Medical Center-Brownsboro, and Kosair
Children’s Hospital)
Lexington, Kentucky
Pikeville Medical Center
Pikeville, Kentucky
St. Elizabeth Physicians Group
Crestview Hills, Kentucky
required vaccinations. Must complete the Agency’s
in-service on HIPAA which will be part of the
student’s orientation process.
NP Students.
Faculty must schedule/coordinate clinical
experience with facility at least 6 weeks in advance
of clinicals.
MSN, DNP
Student: Must obtain health insurance coverage for
the entire term of their clinical. Must read and sign
the Statement of Understanding.
Trover Foundation/Trover Health
Services
Madisonville, Kentucky (Expiredagency will renew upon student
request)
University of Kentucky Medical
Center
Lexington, Kentucky
Students must provide copies of all immunization
records to the site Clinical Education coordinator
MSN, DNP
Students must contact Pat Imerman to set up their
clinicals.
859-257-9196 or p.imerman@uky.edu.
Louisiana
2D Medical Group
Barksdale AFB, Louisiana
Baton Rouge General Medical
MSN
BSN, RN-BSN, MSN,
46
Student must complete the Trainee Agreement
Addendum
Physician Assistant, Physical Therapy,
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
Cardiovascular Institute of the
South
Houma, Louisiana
Children’s Hospital
New Orleans, Louisiana
Children’s Hospital Medical
Practice Corporation
New Orleans, Louisiana
Christus Health Northern
Louisiana
Shreveport, Louisiana
Christus St. Frances Cabrini
Hospital
Alexandria, Louisiana
Christus St. Patrick Hospital
(renewal request sent, set to expire
8/19/2016)
Lake Charles, Louisiana
Coolidge Emergency Group,
LLC
(in conjunction with Lafayette
General Medical Center
agreement)
Morgan City, Louisiana
East Jefferson General Hospital
Metairie, Louisiana
DNP
Occupational 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.
BSN, RN-BSN, MSN,
DNP
RN, RN-BSN, MSN,
NP
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.
LPN, RN, MSN, NP
BSN, RN-BSN, MSN,
DNP
BSN, RN-BSN, MSN,
DNP
NP
NURSING
USA faculty must submit schedule indicating
number and names of students three weeks prior to
clinicals.
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.
Education Contact:
David Potter
CME/GME Coordinator, EJGH
Phone: (504) 503-4283
Email: dpotter@ejgh.org
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.
47
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Franciscan Pace, Inc.
Baton Rouge, Louisiana
MSN, DNP
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.
Health Care Centers in Schools,
Inc., d/b/a Health Centers in
Schools
Baton Rouge, Louisiana
IASIS Glenwood Regional
Medical Center d/b/a Glenwood
Regional Medical Center
West Monroe, Louisiana
Interim LSU Public Hospital
MSN, DNP
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.
MSN, DNP
Student must complete Exhibits A & B.
*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.
(Charity Hospital and Medical
Center of Louisiana at New
Orleans)
New Orleans, Louisiana
USA Faculty please submit attestation
to; Rodney Campbell 504-702-2068
or rodney.campbell@lcmchealth.org
Lafayette General Medical
Center (agreement covers facilities
BSN, RN-BSN, MSN, DNP
that fall under Lafayette Health
Ventures, Inc. , covers Lafayette
General Southwest-contact Monica
Guidry-moguidry@lgh.org)
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
Lallie Kemp Regional Medical
Center
Independence, Louisiana
MSN, DNP
MSN and 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.
RN-BSN, MSN, DNP
48
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Leonard J. Chabert Medical
Center
Houma, Louisiana
Life Net Psychiatry
Mandeville, Louisiana
Louisiana Heart Hospital
Lacombe, Louisiana
Minden Medical Center
Minden, Louisiana
Minden Physician Practices, LLC
d/b/a The Womens Clinic
Minden, Louisiana
NP
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.
MSN, DNP
MSN, DNP
MSN, DNP
Student must contact Allison Ouzts at 318-3713266 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.
Natchitoches Regional Medical
Center
Natchitoches, Louisiana
North Oaks Health System
(includes North Oaks
Rehabilitation Hospital
Hammond, Louisiana
BSN, RN-BSN, MSN,
DNP
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-Assignment Results Form prior to
student beginning clinicals.
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.
49
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Students must complete Attachment 1 (Student
Agreement), Attachment 2 (Confidentiality
Agreement), and Attachment 3 (Statement of
Responsibility) prior to beginning clinicals.
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
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 Attachments 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.
PNP, DNP
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
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
Pediatrix Medical Group of
Louisiana, LLC (services
Women’s and Children’s
Hospital)
Lafayette, Louisiana
Rapides Regional Medical
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.
RN-BSN, MSN, DNP
50
USA/Faculty: Complete Exhibit C and submit to
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Center
Alexandria, Louisiana
Agency (Shelley DauzatShelley.Dauzat@hcahealthcare.com)
Student: Must complete Exhibit A & B.
Regional Medical Center of
Acadiana
Lafayette, Louisiana
Slidell Memorial Hospital &
Medical Center
Slidell, Louisiana
Students must sign Exhibits A and B prior to
beginning clinicals. Faculty must complete Exhibit
C once Mary Meyer has verified.
St. Mary Emergency Group, LLC
at Teche Regional Medical
Center
Lafayette, Louisiana
St. Tammany Parish Hospital
Covington, Louisiana
The Baton Rouge Clinic, AMC
Baton Rouge, Louisiana
Thibodaux Regional Medical
Center
Thibodaux, Louisiana
Touro Infirmary
New Orleans, Louisiana
Touro Infirmary/Crescent City
Physicians
New Orleans, Louisiana
MSN, DNP
NP
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 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.
MSN, DNP
Faculty: Agency requests student specific
statement of liability letter be sent to them (contact
the USA Contracts Office)
MSN, DNP
FNP, NNP
FNP, NNP
51
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.
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.
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.
Faculty must complete Exhibit A. Student must
complete Exhibit B prior to clinicals.
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
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
titer is negative or non-reactive, 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 than 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 than 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.
University Hospital and Clinics
Lafayette, Louisiana
VA Medical Center of
Alexandria, LA
Alexandria, Louisiana
VA Medical Center of New
Orleans
New Orleans, Louisiana
VA Medical Center of Overton
Brooks
Shreveport, Louisiana
Woman’s Hospital
Baton Rouge, Louisiana
Willis-Knighton Health System
MSN, DNP
GAPNP, BSN, MSN
MSN
BSN, RN-BSN, MSN,
DNP
Gerontological/Adult Psychiatric NP (On-Line)
Bachelor and Master
Master of Science
Undergraduate & Graduate degrees in Science of
Nursing
TQCVL Paperwork in agency attachment folder.
Graduate Degree. USA Faculty please ask Dr.
Rhodes to sing the TQCVL form.
BSN, RN-BSN, MSN,
DNP
MSN, DNP
(sites available in Louisiana,
Arkansas and Texas)
Shreveport, Louisiana
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 -complete orientation packet and return
all documentation to agency 21 days prior to clinical
rotation (please see attachments).
Maine
Eastern Maine Medical Center
Bangor, Maine
Pen Bay Medical Center
Rockport, Maine
BSN, MSN
BSN, RN-BSN, MSN,
DNP
52
Agency contact for USA Faculty is Paula
Delahanty, RN, BSN, MHSA. 207-596-8547
pdelahanty@penbayhealthcare.org
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Maryland
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.
Johns Hopkins Bayview Medical
Center
Baltimore, Maryland
Johns Hopkins Hospital Downtown Campus
Baltimore, Maryland
MSN
DNP
NNP
MSN, DNP
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 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.
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 clinical.
Criminal background check and Drug Test must
Franklin Square Hospital Center
(a Med Star Entity)
Rosedale, Maryland
53
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
MSN, DNP
NIH Clinical Center
Bethesda, Maryland
Peninsula Regional Medical
Center
Salisbury, MD
Severna Park Center
Annapolis, Maryland
University of Maryland Medical
Center
Baltimore, Maryland
VA Maryland Health Care
System
Baltimore, Maryland
Walter Reed National Military
Medical Center
Bethesda. Maryland
RN-BSN, MSN, DNP
Nurse Practitioner
BSN, MSN, DNP
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: 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: 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.
Students must maintain health insurance coverage
while in clinicals at Facility.
Student must complete Attachment A prior to
beginning clinicals.
Students must complete the Training Affiliation
Agreement Addendum.
Massachusetts
Agency Name
Beth Israel Deaconess HospitalPlymouth
Plymouth, MA
Agency Requirements
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.
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
Cooley Dickinson Hospital
Northampton, Massachusetts
54
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
MSN, DNP
Southcoast Hospitals Group,
Inc.
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 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.
Students and on-site instructors must complete 10
panel urine drug test prior to beginning clinicals.
Students must complete the student/Instructor
Confidentiality Agreement.
New Bedford, Massachusetts
VA Medical Center of
Northhampton, MA
Leeds, MA
GRADUATE
Graduate Degree
Michigan
Agency Name
Bronson Healthcare Group
Kalamazoo, Michigan
Edward W. Sparrow Hospital
Assoc.
Lansing, Michigan
Oakwood Healthcare, Inc.
(including, OHI, Oakwood, OH
and Medical Center-Dearborn,
Oakwood Heritage, Oakwood
Annapolis, Oakwood
Southshore Medical Center,
and Ambulatory
Dearborn, Michigan
Saint Mary’s of Michigan
Standish Hospital
Saginaw, Michigan
University of Michigan Health
System
Ann Arbor, Michigan
VA Medical Center of Ann Arbor
Ann Arbor, Michigan
Agency Requirements
BSN, RN-BSN, MSN,
DNP
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.
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.
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.
NP
MSN, DNP
Nursing Program, Master’s
55
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
MSN
Minnesota (Minnesota sites should only be utilized by approved USA
students)
Agency Name
Agency Requirements
Children’s Hospital & Clinics of
Minnesota
Minneapolis, MN
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 and to include a mantoux test or
chest x-ray and verification of immunity for rubeola
and rubella.
Essentia Institute of Rural
Health
Duluth, Minnesota
Fairview Health Services
Minneapolis, Minnesota
Minnesota State Community
and Technical College
NNP STUDENTS
ONLY
RN-BSN, MSN, DNP
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.
Students are recommended to have a onetime vaccination of Pertussis (t-dap).
USA/Faculty: Send the student information to the
facility. (Facility contact: Jennifer Jacobson, Dean
of Health, jennifer.jacobson@minnesota.edu-218299-6817).
Moorhead, Minnesota
Student: Must maintain health insurance coverage.
Minneapolis VA Health Care
System
DNP
Minneapolis, Minnesota
St. Cloud VA Medical Center
St. Cloud, Minnesota
56
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
MSN, DNP
University of Minnesota
Physicians
Minneapolis, Minnesota
Mississippi
Anderson Regional Medical
Center and Anderson
Regional Medical CenterSouth Campus
Meridian, Mississippi
Armed Forces Retirement
Home-Gulfport
Gulfport, Mississippi
Baptist Medical Group
MS and TN
Baptist Memorial Hospital –
Golden Triangle
Columbus, Mississippi
Biloxi Regional Medical
Center
Biloxi, Mississippi
Clay County Medical
Corporation d/b/a North
Mississippi Medical CenterWest Point
West Point, Mississippi
BSN, RN-BSN, MSN, DNP
BSN, RN-BSN, MSN,
DNP
MSN, DNP
Faculty must submit schedule and names of students
three weeks prior to clinical rotation.
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.
Graduate
NP
57
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.
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
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
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 PointTupelo 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;
Coastal Family Health Center
Biloxi, Mississippi
BSN, RN-BSN, MSN,
DNP, FNP
Forrest County General
Hospital (to include Marion
General Hospital)
Hattiesburg, Mississippi
George Regional Health
Systems
Lucedale, Mississippi
Hancock Medical Center
Bay St. Louis, Mississippi
Hattiesburg Clinic, PA
Hattiesburg, Mississippi
Highland Community
Hospital/Highland Physicians
Clinic
Picayune, Mississippi
Keesler Medical Center, 81st
Medical Group,
Keesler AFB, Mississippi
Memorial Hospital at Gulfport
Gulfport, Mississippi
RN-BSN, MSN, DNP
Merit Health Woman’s
Hospital
Flowood, MS
Faculty: please call Ms. Chris Maurice at 228-374-2494
ext. 1019 to coordinate preceptor.
Please see Exhibit C for any additional requirements.
BSN, RN-BSN, MSN,
DNP
BSN, RN-BSN, MSN,
DNP
BSN, RN-BSN, MSN,
DNP
MSN, DNP
Please see Exhibit C for specific requirements.
Students are required to submit fingerprints to agency.
Students shall maintain comprehensive healthcare
insurance during clinicals.
All students must check in with Major Garrett Miller
(garrett.miller@us.af.mil). He will assist with all clinical
rotations at Keesler.
MSN
BSN, RN-BSN, MSN,
DNP
(Indoor and Outdoor) Tobacco free environment
Fingerprinting is required. Student pays $50 fee to
hospital.
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
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 interferon-gamma 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
Nursing
58
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
the series, or informed refusal of the vaccine; and (c)
any other appropriate immunizations requested by
Facility. Must have health insurance.
Mississippi State Hospital
Whitfield, Mississippi
Mississippi State Department
of Health
Undergraduate and
Graduate Students
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.
(Renewal request sent, set to expire
7/31/2016)
Jackson, Mississippi
North Mississippi State
Hospital
Tupelo, Mississippi
North Mississippi Medical
Center-Pontotoc
Pontotoc, MS
North Mississippi Medical
Center-Tupelo
Tupelo, Mississippi
NP
NP
USA/Faculty: Annual joint meeting to evaluate the
Clinical Education Program.
Nursing and Nurse
Practitioner Programs
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) 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.
59
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
OCH Regional Medical
Center
Starkville, Mississippi
River Oaks Hospital
Jackson, Mississippi
Rush Health System (to include
all of its subsidiaries and affiliated
entities)
Meridian, Mississippi
BSN, RN-BSN, MSN,
DNP
USA/Faculty: See Addendum 1 & 2 -Patient Care
Duties.
Student: Complete Addenda 4, 5, and 7.
Nursing
BSN, RN-BSN, MSN,
DNP
Select Specialty Hospital Gulf Coast, Inc.
Gulfport, Mississippi
Singing River Health System
(renewal request sent, set to
expire 6/1/2016)
Pascagoula, Mississippi
St. Dominic-Jackson
Memorial
Jackson, Mississippi
The Diabetes Center
Ocean Springs, Mississippi
University of Mississippi
Medical Center and all of
UMMC’s Clinics
Jackson, Mississippi
BSN, RN-BSN, MSN,
DNP
BSN, RN-BSN, MSN,
DNP
BSN, RN-BSN, MSN,
DNP
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.
For Preceptor Kathleen Arnold-please find her CV and
current License Verification under agency attachments.
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.
60
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Students must complete Epic System Training. Visit
affiliated student webpage www.umc.edu, and then click
on Education tab, then affiliated students under
Resources.
Veterans Affairs Gulf Coast
Healthcare System
Biloxi, Mississippi
BSN, MSN,
GRADUATE
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 Medical Center - G.V.
(Sonny) Montgomery
Jackson, Mississippi
Wesley Medical Center
Hattiesburg, Mississippi
GERON/ACUTE NP,
PRIMARY INLUDING
PRIMARY CARE,
ACUTE NP (MSN),
FAMILY NP (MSN),
BSN, MSN, ENP,
CLINICAL NURSE
LEADER (MSN)
BSN, RN-BSN, MSN,
DNP
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.
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)
“Student Agreement Only”-Students should complete
a Term Sheet from the agency Now includes FNP
students Agency contact is Terry Trigg Tel: (601) 2688058.
Missouri
509th Medical Group
Whiteman AFB, Missouri
Barnes-Jewish Hospital
St. Louis, Missouri
RN-BSN, MSN, DNP
CNS
Student must complete Trainee Agreement
Addendum
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.
61
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Barnes-Jewish Hospital
St. Louis, Missouri
NP, DNP
BJC Hospice
St. Louis, Missouri
DNP, NP
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.
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.
Boone Hospital Center
Columbia, Missouri
Central Missouri Physicians for
Women (Michael L. Burks, M.D.,
P.C.)
Columbia, Missouri
Children’s Mercy Hospital and
Clinics
Kansas City, Missouri
Cox Health (includes Lester E.
Cox Medical Center)
Springfield, Missouri
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.
BSN, RN-BSN, MSN,
DNP
BSN, RN-BSN, RNMSN
BSN, RN-BSN, MSN,
DNP
62
Faculty and student review exhibit A.
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
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
screen prior to clinicals.
Family Health Care Center
Saint Louis, Missouri
Freeman Health System
Joplin, Missouri
Heartland Regional Medical
Center d/b/a Mosaic Life Care
St. Joseph, Missouri
MSN, DNP
MSN, DNP
BSN, RN-BSN, MSN, DNP
Faculty, any correspondence with preceptors must
be copied to Mr. Dennis Kruse, CFO-401 Holly Hills
Avenue, St. Louis, MO 63111-2410
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.
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
IPC -InPatient Consultants of
Missouri, Inc. (Preceptor
Agreement Only-Must have
correlating agreement with
facility)
St. Louis, Missouri
RN-BSN, MSN, DNP
*Must accompany an agreement
with Facility*
63
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:
●
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.
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.
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
Physician Groups, LC dba BJC
Medical Group of Missouri
St. Louis, Missouri
SSM Health
St. Louis, Missouri
St. Louis Children’s Hospital
St. Louis, Missouri
University of Missouri Health
Care
Columbia, Missouri
BSN, RN-BSS, MSN,
DNP
USA/Faculty: Provide facility with student names,
health status reports, immunizations prior to
clinicals. 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.
MSN, DNP
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.
Faculty, please request a copy of the “additional
terms” form prior to students beginning clinicals
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 3-Confidentiality
Agreement. Upon Facility’s request provide
evidence of Hepatitis B vaccine or a signed
statement declining Hepatitis B vaccine.
Billings Clinic
Billings Montana
MSN, DNP
St. Vincent Healthcare
Billings, Montana
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.
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
VA Medical Center of St. Louis,
MO
St. Louis, Missouri
Montana
64
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Hospital’s insurance programs or benefit program’s
to include Worker’s Compensation.
Nebraska
Alegent Health
Omaha, Nebraska
Nebraska Methodist Hospital
Omaha, Nebraska
Saint Francis Medical Center
Grand Island, Nebraska
NP
MSN, DNP
AGACNP
Adult Gerontological Acute Care NP program.
Student must complete and sign Exhibit A. Faculty
please see Exhibit B.
Nevada
99th Medical Group, Mike
O’Callaghan Federal Hospital
Nellis Air Force Base, Nevada
Carson Tahoe Health
Carson City, Nevada
MonteVista Hospital
Las Vegas, Nevada
MountainView Hospital
Las Vegas, Nevada
Nathan Adelson Hospice
Las Vegas, Nevada
VA Sierra Nevada Health Care
System
Reno, Nevada
Valley Health system, LLC ( to
include: Centennial Hills
ADVANCED
PRACTICE
NP
Student must complete Trainee Agreement
Addendum
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:
CJ Ojanpera
cj.ojanpera@carsontahoe.org
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.
RN-BSN, MSN, DNP
MonteVista Hospital
Las Vegas, Nevada
MSN, DNP
USA/Faculty: Must complete Exhibit C-Attestation
Student: Must complete Exhibits A-B. Must pass a
physical examination at least once a year.
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.
MSN, DNP
65
USA Faculty must notify hospital of planned clinical
training experience, area, date of arrival, name of
student. Provide a copy of the performance
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
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.
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
New Hampshire
Elliot Health System
Manchester, New Hampshire
Mary Hitchcock Memorial
Hospital,
Dartmouth-Hitchcock Clinic
Lebanon, New Hampshire
Southern New Hampshire
Health System
Nashua, New Hampshire
BSN, MSN, DNP
NP
MSN, DNP
Speare Memorial Hospital
Plymouth, New Hampshire
66
USA/Faculty: Must provide clinical practicum
objectives to facility. (Deborah Langton - 603-6632715).
Student must complete Confidentiality Agreement
through agency.
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.
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 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.
Faculty, provide information regarding curriculum
and clinical education goals associated with the
clinical rotation. Must notify agency within 1 month
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
MSN, DNP
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.
New Jersey
Cooper University Hospital
Camden, New Jersey
Hackensack University Medical
Center
Hackensack, New Jersey
Inspira Health Network, Inc. (to
include Inspira Medical CenterElmer and Inspira Medical
Center-Vineland)
Woodbury, NJ
Robert Wood Johnson
University Hospital
New Brunswick, New Jersey
Attachments to be completed by faculty and student
RN-BSN, MSN, DNP
Nursing
RN-BSN, MSN, DNP
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 and Students please read the
Conditions of Participation/NIAHO at the following
website: https://www.cms.gov/Regulations-andGuidance/Legislation/CFCsAndCoPs/Hospitals.html.
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.
South Jersey Hospital, Inc.
(aka Bridgeton Mental Health
Unit)
Bridgeton, New Jersey
Virtua Health, Inc. (includes:
MSN, DNP
GRADUATE
67
USA/Faculty: Provide certification that the student is
in good health.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
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.
Virtua-West Jersey Health and
Virtua-Memorial Hospital
Burlington County)
Marlton, New Jersey
New Mexico
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.
377th Medical Group, Kirtland
AFB
New Mexico
Christus-St. Vincent Regional
Medical Center
Santa Fe, New Mexico
Lovelace Health System
Albuquerque, New Mexico
Navajo Area Indian Health
Service (to include: Gallup Indian Medical
BSN, MSN, DNP
BSN, RN-BSN, MSN,
DNP
RN-BSN, MSN, DNP
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
68
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 program.
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.
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.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
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
University of New Mexico
Hospital
Albuquerque, New Mexico
University of New MexicoSandoval Regional Medical
Center
Student must sign and complete Exhibit B prior to
beginning clinicals.
MSN, DNP
MSN, DNP
(renewal request sent, set to expire
8/1/2016)
Rio Rancho, New Mexico
VA Medical Center of New
Mexico
Albuquerque, New Mexico
BSN, MSN
Agency requires student(s) be complete drug
screening within 6 months before beginning
clinicals 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.
BSN and MSN
New York
* At this time students may not preform clinical experiences in this state.*
North Carolina
4th Medical Group
Seymour Johnson AFB, North
Carolina
Appalachian Regional
Healthcare
Boone, North Carolina
MSN, DNP
69
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
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
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 Blood borne Pathogens and TB
or other applicable guidelines upon request.
Student: Must obtain adequate health
insurance.
Bladen County Health
Department
ADVANCED
EMERGENCY NP
(renewal request sent, set to expire
8/19/2016)
Elizabethtown, North Carolina
Blue Ridge Healthcare
(Renewal request sent, set to expire
7/31/2016)
Morganton, North Carolina
Brynn Marr Behavioral
Healthcare System
Jacksonville, North Carolina
Cape Fear Valley Health System
(Bladen County Healthcare)
Elizabethtown, North Carolina
BSN, RN-BSN, MSN,
DNP
BSN, NP
ADVANCED
EMERGENCY NP
Students must be trained consistent with
applicable requirements by facility to the
facility’s policies and procedures.
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.
Students: Must comply with the policies and
procedures provided by Health System.
CarolinaEast Health System (to
include CarolinaEast
Physicians)
New Bern, North Carolina
CarolinaEast Medical Center
and Emergency Medicine
Physicians of Craven County (3way agreement)
New Bern, North Carolina
Gaston Health Care, Inc. d/b/a
CaroMont Health
Gastonia, North Carolina
Catawba Valley Medical Center
Hickory, North Carolina
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
CNS, CNL
RN-BSN, MSN, DNP
70
Only for CNL and CNS Students
USA Faculty: Upon request please provide the
following;

Objectives of the Experience

Course Titles

Number of Students

Dates, days and times of Experiences
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered


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
NP
AMISUB of North Carolina, d/b/a
NP
Central Carolina Hospital
(part of the Tenet Healthcare
Corporation)
Sanford, North Carolina
Charlotte Mecklenburg Hospital
Authority d/b/a Carolinas
HealthCare System (Covers ALL
CHS facilities)Charlotte, North
Carolina
BSN, RN-BSN, MSN,
DNP
71
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.
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 onsite 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.
Student: Must complete Exhibit A-Confidentiality
Statement. Student must comply with the final
regulations issued by OSHA governing employee
exposure to blood borne pathogens in the
workplace.
USA/Faculty: Please see training modules in
PubDocs 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 History screening
(FCH Screen), to include a fingerprint check in
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Community CarePartners, Inc.
Asheville, North Carolina
BSN, RN-BSN, MSN,
DNP
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.
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 bloodborne
pathogens, personal protective equipment, and
other measures designed to avoid exposure to
bloodborne pathogens. TB test completed on
annual basis.
Cornerstone Health Care, P.A.
High Point, North Carolina
BSN, RN-BSN, MSN,
DNP
Cumberland County Health
Department
Fayetteville, North Carolina
Cumberland County Hospital
System, Inc. d/b/a Cape Fear
Valley Health System
Fayetteville, North Carolina
Duke University Affiliated
Physicians, Inc.
Durham, North Carolina
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
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.
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).
Only for Acute Care Nurse Practitioner students.
Duke University Health System,
Inc.
Durham, North Carolina
Durham VA Medical Center
Durham, North Carolina
Gaston Health Care, Inc. d/b/a
CaroMont Health
Gastonia, North Carolina
Grace Medical Clinics, PA
USA/Faculty- please see the EMR agreement for
reference to the student completing Exhibit 1.
Students- Must complete and sign Exhibit 1.
MSN, DNP
(renewal request sent, set to expire
8/11/2016)
72
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Charlotte, North Carolina
High Point Regional Health
High Point, North Carolina
Kinston Community Health
Center, Inc.
RN-BSN, MSN, DNP
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.
MSN, DNP
(renewal request sent, set to expire
8/13/2016)
Kinston, North Carolina
Mission Hospital, Inc. and
Carolina Mountain Emergency
Medicine, PA.
Asheville, North Carolina
MMA-Vista Family Health, Inc.
Asheville, North Carolina
ONLY the following
programs are covered
DNP-Family Psych
MSN-CNS
MSN-FNP
Pediatric Primary NP
Moses H. Cone Memorial
Hospital d/b/a Cone Health
Greensboro, North Carolina
Naval Health Clinic Cherry Point
Marine Corp Air Station
Cherry Point, North Carolina
Naval Hospital, Camp Lejeune
Camp Lejeune, North Carolina
New Hanover Regional Medical
Center
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.
MSN-FNP ONLY
Agency Contact: Education Services 828-213-0779
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.
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.
Nurse Practitioner
RN-BSN, MSN, DNP
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
(renewal request sent, set to expire
8/1/2016)
Wilmington, North Carolina
73
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
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
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.
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 facility upon request for a period of 3 years.
Must maintain health insurance coverage.
Piedmont HealthCare
Statesville, North Carolina
Pinehurst Medical Clinic
Pinehurst, North Carolina
Stanly Health Services, Inc.
Albemarle, North Carolina
BSN, RN-BSN, MSN,
DNP
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
MSN, DNP
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.
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 screen 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
74
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
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
W.G. (Bill) Hefner VA Medical
Center
Salisbury, North Carolina
VA Medical Center of Asheville,
NC
Asheville, North Carolina
VA Medical Center of
Fayetteville
Fayetteville, North Carolina
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)
BSN, RN-BSN, MSN,
DNP
Faculty must complete the Clinical Education,
Clinical Instructor, and Request for use of Clinical
Facilities forms. prior to the student beginning
clinicals
Advanced Practice Nursing
ADVANCED
PRACTICE
NP
BSN, RN-BSN, MSN,
DNP
Greenville, North Carolina
Wake Forest University Baptist
Medical Center (North Carolina
Baptist Hospital)
Winston-Salem, North Carolina
Womack Army Medical Center
Ft. Bragg, North Carolina
MSN, DNP
Nurse Practitioner
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.
For Clinical Faculty and Students additional on-site
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.
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.
North Dakota
5th Medical Group-Minot AFB
MSN and DNP
Student must complete Trainee Addendum
75
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Minot AFB, North Dakota
Altru Health Systems
Grand Forks, North Dakota
Northeast Human Service
Center
Grand Forks, North Dakota
BSN, RN-BSN, MSN,
DNP
Students and Faculty: Request to see Addendum
under Agreement Attachments (immunization
requirements). See Orientation Information in
Agency Attachments.
Nursing
USA/Faculty: Provide students name, level of
academic preparation, length and dates of
experience.
Student: Must complete Student Waiver
Form.
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.
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
applicable.
Prior notice of any proposed changes to any
assigned student's schedule.
Sanford North
Fargo, North Dakota
Ohio
Adena Health System
Chillicothe, Ohio
MSN, DNP
Agency contact: Monica Climer, Coordinator
Graduate Clinical Student-mclimer@adena.org740-779-8821
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.
Akron General Medical
Center
Akron, Ohio
Graduate
76
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
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
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.
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.
Cincinnati Children’s Hospital
Medical Center
Cincinnati, Ohio
Collaborative Care Services, Inc.
(Optum Health)
also covers (Southwest Medical
Associate clinics including
urgent care in Southern NV)
West Chester, Ohio
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
BSN, RN-BSN, RNMSN
This agreement is ONLY in effect for Cincinnati
Children's Hospital Medical Center employees.
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.
Dayton VA Medical Center
Dayton, Ohio
MSN, DNP
MSN and DNP programs.
Grandview Medical Center
Dayton, Ohio
MSN, DNP
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: 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
Kettering Health Network
Dayton, Ohio
77
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Knox Community Hospital
Mount Vernon, Ohio
MSN, DNP
Exhibit C.
Students: Provide proof of health insurance to
facility. Must sign Exhibit B - Student Orientation
Form.
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.
Lima Memorial Health System
MSN, DNP
(renewal request sent, set to expire
6/30/2016)
Lima, Ohio
Mercy Health Cincinnati LLC
Cincinnati, Ohio
Mercy St. Vincent Medical
Center
Toledo, Ohio
OhioHealth Corporation (to
Students must read and sign Attachment A
(Administrative Confidentiality Policy).
MSN, DNP
Exhibit A must be completed prior to beginning
clinicals.
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
include: 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
Soin Medical Center (Kettering
Health Network affiliate)
Beaver Creek, Ohio
Agency requires student & faculty names and
schedule of clinicals 3 weeks prior to beginning.
Students must contact Terri Metzger to sign LON tmetzger@limamemorial.org (as of 10/11/2013)
Student: Must obtain health insurance coverage.
Students please request information about Ohio
Board of Nursing Requirements(Attachment A)
MSN, DNP
Faculty members please see me regarding
attachment A prior to student’s clinical experience
USA Faculty: Must provide all objectives, policies,
and evaluation instruments to be utilized to
preceptors. Review Exhibit A (Immunization
Requirements).
Students: Must complete and sign Exhibit B. Must
provide Hospital with documentation evidencing
background check. Must provide proof of health
insurance to Hospital.
Springboro Family Medicine
(only with preceptor, Dr. Dori
MSN, DNP
78
USA/Faculty: Exhibits A-C must be completed by
student; Faculty will be the contact person for
student. Submit all requested student information to
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
facility within 30 days prior to clinicals.
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.
Thompson)
Dayton, Ohio
Summa Health System Hospitals
Akron, Ohio
Summa Physicians, Inc.
Akron, Ohio
The Christ Hospital
Cincinnati, Ohio
The Toledo Hospital
Toledo, Ohio
UC Health (to include The Drake
Center and West Chester
Hospital) and University of
Cincinnati Physicians Company,
LLC
VA Medical Center of Cincinnati
Ohio
Cincinnati, Ohio
NP
Students: Must maintain health insurance and
provide proof of such insurance to agency. See
attachment for agency immunization requirements.
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.
MSN
MSN, DNP
BSN, MSN, DNP
Student must complete and sign Exhibit A
Confidentiality Agreement.
BSN and Graduate Nursing Students
Oklahoma
AHS Oklahoma Health System,
LLP (Utica Park Clinic)
Tulsa, Oklahoma
Choctaw Nation of Oklahoma
Health Services Authority
Talihina, Oklahoma
MSN, DNP
See Exhibit A for covered facilities. See Exhibit C
for Background Requirements.
Student must complete and sign Exhibit D.
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.
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.
79
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Comanche County Hospital
Authority
Lawton, Oklahoma
Deaconess Health System, LLC
Oklahoma City, OK
INTEGRIS Health, Inc. (and
affiliated entities)
Oklahoma City, Oklahoma
NP
Graduate Nursing
Programs
USA/Faculty: Provide clinical instructor name and
student roster at least10 days prior to clinical. 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: 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.
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.
Jack C. Montgomery VAMC
Muskogee, Oklahoma
McAlester Regional Health
Center
McAlester, Oklahoma
Medical Center of Southeastern
Oklahoma
Durant, OK
Mercy Clinic Communities, Inc.
Oklahoma City, Oklahoma
BSN, RN-BSN, MSN,
DNP
RN-BSN, MSN, DNP
NP
Mercy Hospital-Ardmore
Ardmore, Oklahoma
NP
Mercy Hospital Oklahoma City,
NP
80
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.
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.
Student: Must attend orientation provided by
agency.
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
USA/Faculty: Shall provide student names,
schedules, activities to be carried out in the clinical
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
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.
Inc.
Oklahoma City, OK
Students: Must complete orientation from facility.
Midwest Regional Medical
Center
Midwest City, Oklahoma
Oklahoma City Area Indian
Health Service (covers, White Cloud
USA/Faculty and Students: See Addenda 1-5 for
additional requirements.
BSN, RN-BSN, MSN,
DNP
Health Station, 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
OU Physicians
Oklahoma City, Oklahoma
Saint Francis Health System,
Inc.
Tulsa, Oklahoma
Seminole Medical Center
Seminole, Oklahoma
MSN and NP
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. 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.
Student must complete Attachment A, “Affiliation
Confidentiality Agreement,” prior to beginning
clinicals.
Graduate advisor to confirm background check with
agency and faculty to contact agency prior to
students beginning clinicals.
USA/Faculty: See Addendum 1-3.
Student: Must complete Addendum 4 & 5. Must
have health insurance.
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.
Southwestern Regional Medical
Center, Inc.
Tulsa, Oklahoma
Student: Meet the personal, ethical and
professional standards required of employees of
81
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
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.
St. John Medical Center, Inc.
Tulsa, Oklahoma
MSN, DNP
USA/Faculty: Please provide a roster of student/
faculty names and rotating schedule to agency
contact: Ebony Fultz-ebony.fultz@sjmc.org-918744-3602. 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.
Tulsa City-County Health
Department
Tulsa, Oklahoma
MSN, DNP
University of Oklahoma, School
of Community Medicine
Tulsa, Oklahoma
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.
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.
MSN Students.
VA Medical Center Oklahoma
City
(Renewal request sent, set to expire
7/31/2016)
Oklahoma City, Oklahoma
Oregon ***
Asante Physician Partners
Medford, Oregon
BSN, RN-BSN, MSN,
DNP
82
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
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
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].
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)
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.
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.
Providence Health and Services
(Oregon Region)
Portland, Newberg, Hood River,
Seaside, Medford
Portland, Oregon
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 an Oregon APRN license.
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 Blood borne
Pathogen training. Complete OHSU’s HIPAA
Privacy Training prior to beginning clinical at
OHSU. Provide OHSU with proof of having
successfully passed criminal background screening
and drug screening.
USA/Faculty: Provide agency with copies of
Samaritan Health Services, Inc.
83
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
curriculum, education goals, and requirements and
qualifications of Students. Provide agency with
clinical rotation plan and clinical education
objectives for the Learning Practicum for agency’s
review.
Students: Provide own health insurance.
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 Bloodborne Pathogens, BLS, Sliverton Health
online competency lessons. Flu Vaccine (OctoberMarch). Facility contact: Jocelyn Lewis at
jlewis@silvertonhealth.org or 503-873-5292.
Corvallis, Oregon
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 an Oregon APRN license.
VA Medical Center of Portland,
OR
Portland, Oregon
GERON/ADULT
PSYCHIATRIC, MSN
Gerontological/Adult Psychiatric, Masters
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.
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.
VA Roseburg Healthcare
System
Roseburg, Oregon
Pennsylvania
Conemaugh Memorial Medical
Center
Johnstown, Pennsylvania
MSN, DNP
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
84
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
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 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.
Geisinger Health System
Danville, Pennsylvania
MSN, DNP
85
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: 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
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Penn State Milton S. Hershey
Medical Center
Hershey, Pennsylvania
Pottstown Memorial Medical
Center
Pottstown, Pennsylvania
Reading Hospital
West Reading, Pennsylvania
NP
Pinnacle Health (Pinnacle Health
MSN, DNP
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.
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: Complete Addenda 4 & 5. Must have
health insurance during clinical rotation at Facility.
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.
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 Xray 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.
Hospitals, Pinnacle Health Medical Services,
Pinnacle Health Cardiovascular Institute,
Pinnacle Health Medical Group)
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.
Harrisburg, Pennsylvania
Students: Students: See Student website:
http://www.pinnaclehealth.org/JobOpportunities/Student-Career-Information.aspx
Encouraged to obtain hospital health insurance
86
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
St. Mary Medical Center
Langhorne, PA
Take Care Health Systems, LLC
Conshohocken, Pennsylvania
VA Stars and Stripes Healthcare
Network
Lebanon, Pennsylvania
Saint Luke’s Hospital of
Bethlehem (to include locations at:
MSN, DNP
NP
Nurse Practitioner
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.
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.
NP STUDENTS
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.
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.
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. Student statement of responsibility.
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.
87
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
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.
WellSpan Health
York, Pennsylvania
DNP
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.
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.
Rhode Island
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.
88
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
South Carolina
AnMed Health
Anderson, South Carolina
Augustine Health Group, LLC
Columbia, South Carolina
East Cooper Medical Center
Mount Pleasant, South Carolina
BSN, RN-BSN, MSN,
DNP
NP
RN-BSN, MSN, DNP
Faculty should contact Tajuane Dockery 803-8654793 tajuane.dockery@providencehospitals.com to
schedule students participating in clinicals.
Students complete Exhibit B.
*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.
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.
Mary Black Hospital
Please read, student list of requirements
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.
NP’s ONLY
(Renewal request sent, set to expire
7/31/2016)
Spartanburg, South Carolina
McLeod Medical Center-Dillon
Florence, South Carolina
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
BSN, RN-BSN, MSN,
DNP
89
USA/Faculty: Must submit programs of instruction
to facility no later than two weeks prior to beginning
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
of each semester. Advanced notice of clinical
assignments, including dates, hours, number of
students, assigned instructors, and type of
experience. Keep facility informed as to needs of
the Program in order to comply with the standards
outlined in Essentials of an Accredited Education
Program as published 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.
Darlington, South Carolina
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.
Medical University Hospital
Authority
Medical University of South
Carolina
NP
Code of Conduct and Communicable Disease
Attestation on file.
Contact: Teresa Guyton 843-792-0623.
(Renewal request sent, set to expire
7/31/2016)
Charleston, South Carolina
Moncrief Army Community
Hospital
Fort Jackson, SC
Naval Health Clinic-Goose
Creek
Charleston, South Carolina
Newberry County Memorial
Hospital
Newberry, South Carolina
Palmetto Medical Initiative
Charleston, South Carolina
Pediatrix Medical Group of
South Carolina, PA and
Palmetto Health
Columbia, South Carolina
FAMILY
PSYCHIATRIC NP
NP
Family Psychiatric Nurse Practitioner students.
Students must complete Student Packet (in
attachments folder). Once completed students must
contact the Hospital Education Department 803751-2488.
Student must complete Trainee Agreement.
Undergraduate and
Graduate Students
BSN, RN-BSN, MSN, DNP
NNP Students ONLY
Students: Shall be responsible for Agency program
costs as outlined by Agency, from time to time, for
particular programs.
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
90
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Ralph H. Johnson VA Medical
Center
Charleston, South Carolina
MSN
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 steps 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
Sisters of Charity Providence
Hospital
Columbia, South Carolina
registration. Must complete Confidentiality
Agreement available from Hospital.
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.
MSN, DNP
Faculty should contact Tajuane Dockery 803-8654793 tajuane.dockery@providencehospitals.com to
schedule students participating in clinicals.
Students complete Exhibit B.
South Carolina Department of
Health and Environmental
Control
Columbia, South Carolina
South Carolina Department of
Mental Health (SCDMH)
(Division of Inpatient Services)
Columbia, South Carolina
Spartanburg Regional Health
Services District, Inc.
Spartanburg, South Carolina
St. Francis Physician
Services/St. Francis Hospital
Greenville, South Carolina
VA Medical Center (Wm.
Jennings Dorn)
Columbia, South Carolina
Nursing
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.
Students must complete the following annually:
South Carolina Sexual Offender Registry
Background Check.
South Carolina Law Enforcement Division (SLED)
Criminal Records Check. 10 Panel Drug Test
MSN, DNP
MSN-Family Pysch
Only
91
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.
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.
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
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
South Dakota
Avera Health (to include Avera
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
Regional Health
Rapid City, South Dakota
Sanford Health
Sioux Falls, South Dakota
BSN, RN-BSN, MSN,
DNP
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
MSN
MSN, DNP
92
Student: Must complete Attachment 1.
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).Students must review and complete the
Sanford Health Orientation 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.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Tennessee
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.
Programs: RN-BSN, MSN, PM Cert, DNP
Baptist Memorial Hospital-Union
City
Union City, Tennessee
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.
USA/Faculty: Must complete Exhibit C-Attestation
and submit to agency.
Centennial Heart, LLC
Nashville, Tennessee
Student: Must complete Exhibits A&B and submit to
agency.
Chattanooga-Hamilton County
Hospital Authority d/b/a Erlanger
Health System
Chattanooga, Tennessee
Cookeville Regional Medical
Center
Cookeville, Tennessee
Correct Care Solutions, LLC
(corporate office)
BSN, RN-BSN, MSN,
DNP
Psych NP Only
(renewal request sent, set to expire
8/1/2016)
Nashville, Tennessee
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.
Danita’s Children
Nashville, Tennessee
Dyersburg Regional Medical
Center
Dyersburg, Tennessee
Nursing
BSN, RN-BSN, MSN,
DNP
93
USA/Faculty: Provide written documentation on:
student’s immunizations, to include TB skin test
within past year or if positive test, chest x-ray 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).
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Copy of forms must be on file at facility before
student may begin clinicals.
East Tennessee Children’s
Hospital
Knoxville, Tennessee
HCA Health Services of
Tennessee, d/b/a Centennial
Medical Center
Nashville, Tennessee
Jackson-Madison County
General Hospital,
West TN Healthcare
Jackson, Tennessee
Maury Regional Hospital d/b/a
Maury Regional Medical Center
Columbia, Tennessee
Memorial Health Care System,
Inc.
Chattanooga, TN
Methodist LeBonheur Healthcare
(covers: University,
Germantown, North, South,
Olive Branch, and Le Bonheur
Chidlren’s Hospital, and many
clinics)
Memphis, Tennessee
Regional One Health (Outpatient
Centers)
Memphis, Tennessee
Regional One Health (Regional
Medical Center at Memphis)
Memphis, Tennessee
MSN, DNP
Student: Must adhere to Substance Policy. See
Addendum 4. Must have health insurance during
clinicals at facility.
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.
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
BSN, RN-BSN, MSN, DNP
MSN, DNP
USA/Faculty: Must complete Exhibit A.
Student: Must have BLSHC Provider CPR.
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.
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.
Students must sign Exhibit A (Hepatitis Statement)
prior to beginning clinicals. Students must show
documentation of flu vaccine. As of January 1,
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.
Undergraduate and
Graduate
MSN, DNP
94
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
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
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.
Saint Francis Hospital-Bartlett
MSN, DNP
(effective 8/1/2015)
Bartlett, Tennessee
Skyline Medical Group
Nashville, Tennessee
MSN, DNP
(Renewal Request sent, set to
expire 6/2016)
Southeastern Emergency
Physicians, LLC & Southeastern
Emergency Services, P.C.
(in accordance with the Maury
Regional Hospital agreement)
Knoxville, Tennessee
St. Francis Hospital
Memphis, Tennessee
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.
Student: Must complete Exhibit A-Statement of
Responsibility and Exhibit B-Confidentiality
Statement.
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.
Agreement covers preceptor at said facility only.
Dual Role
(FNP/AGACNP)
* Agreement for Advanced Emergency Nurse
Practitioner Students Only*
USA/Faculty: Complete Exhibit C-Attestation.
Students: Must complete Exhibit A-Statement of
Responsibility and Exhibit B-Confidentiality
Statement. Must have received OSHA training
pertaining to exposure to blood borne pathogens in
the workplace.
St. Jude Children’s Research
Hospital
Memphis, Tennessee
Tennessee Valley Healthcare
System (All-Sites)
Nashville, Tennessee
TriStar Horizon Medical Center
BSN, RN-BSN, MSN,
DNP
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. Must obtain medical insurance and
provide copy to USA. Complete
Exhibits A & B.
MSN
Advanced Emergency
95
USA/Faculty: See Exhibit A-Background Check
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
NP
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.
Tri Star Skyline Medical Center
& Tri Star Skyline Madison
Campus
Nashville, Tennessee
MSN, DNP
University Health System, Inc.
(University of Tennessee)
Knoxville, Tennessee
VA Medical Center of Memphis,
TN
Memphis, Tennessee
Vanderbilt University Medical
Center (Hospital, Clinic,
Children’s Hospital)
Nashville, Tennessee
RN-BSN, 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 Hepatitis 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
Please see Exhibits A& B and Influenza Form.
Dickson, Tennessee
MSN, DNP
(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.
Veterans Affairs Outpatient
Clinic
Chattanooga, Tennessee
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.
Graduate, MSN
Graduate Program,
Master of Science in Nursing
Texas
Baptist Health System
San Antonio, Texas
BSN, RN-BSN, MSN,
DNP
96
*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
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Bayshore Medical Center
Pasadena, Texas
Carl R. Darnall Army Medical
Center
Fort Hood, Texas
CHI St. Luke’s Sugar Land
Hospital
Sugarland, Texas
Children’s Medical Center of
Dallas
Dallas, Texas
MSN, DNP
clinicals. (See faculty member regarding form).
USA/Faculty: Provide letter of attestation for each
student.
Student: Complete Exhibits A & B.
Nursing
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.
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.
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, 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.
Christus Santa Rosa Health
Care
San Antonio, Texas
Christus Spohn Health System
Corp.
Corpus Christi, Texas
Cook Children’s Hospital (to
include the Physician Network)
Fort Worth, Texas
Corpus Christi Medical Center
(Bay Area Healthcare Group,
Ltd.)
Corpus Christi, Texas
Graduate Nursing
BSN, RN-BSN, MSN,
DNP
Faculty must provide facility with written
curriculum, evaluation methodologies and a set
of Student objectives and complete Exhibit A.
USA/Faculty: Please see Exhibit A Background
Check/Drug Screen for agency requirements per
the agreement.
MSN, DNP
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
97
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
certificate of declination of vaccine. Facility must
have access to the background investigation.
Background check must include the Texas HHS
List of Excluded individuals.
Driscoll Children’s Hospital
Corpus Christi, Texas
MSN, DNP
DSHS Rusk State Hospital
Rusk, Texas
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.
Ector County Hospital
District/Medical Center Health
System
Odessa, Texas
Genesis PrimeCare
Marshall, Texas
Good Shepherd Medical CenterMarshall
Marshall, Texas
HCA North Texas (includes Denton
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: 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 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.
RN-BSN, MSN, DNP
Genesis PrimeCare
Marshall, Texas
Nurse Practitioner Program
Only
BSN, RN-BSN, MSN,
98
Students must complete Exhibit A (Statement of
Responsibility) and Exhibit B (Confidentiality
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
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
Health Texas Provider Network
and Baylor University Medical
Center
Dallas, Texas
Hunt Regional Healthcare
Greenville, Texas
Huntsville Memorial Hospital
Huntsville, Texas
DNP
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.
APRN
Student: Must participate in the orientation provided
by the Hospital and Group. Must maintain adequate
health insurance throughout clinical experience.
Complete Confidentiality Agreement.
BSN, RN-BSN, MSN,
DNP
RN-BSN, MSN, DNP
Memorial Hermann Medical
Group
Houston, Texas
MSN, DNP
Memorial Hermann Northwest
Hospital
Houston, Texas
Memorial Hermann Southwest
Houston, Texas
Memorial Hermann The
Woodlands Hospital
The Woodlands, Texas
Methodist Health System (to
include: Methodist Dallas
Medical Center, Methodist
Charlton Medical Center,
Methodist Mansfield Medical
Center, and Methodist
Richardson Medical Center
Richardson, Texas
Pediatrix Emergent & Critical
Care Services, LLC
Richardson, Texas
Pediatrix Medical Services, Inc.
Richardson, Texas
MSN, DNP
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.
MSN and DNP Students
USA/Faculty: Please contact Dr. Elliselizabeth.ellis2@memorialhermann.org and
VanessaJagassarvanessa.jagassar@memorialhermann.org for
student placement.
Students: Must complete Exhibit B-HIPAA Form.
Students must complete Exhibit B prior to
beginning clinicals.
MSN, DNP
MSN, DNP
Students must complete Exhibit B prior to
beginning clinicals.
MSN, DNP
Faculty please see Exhibits A&B. Students must
sign Exhibit C.
Graduate
BSN, RN-BSN, MSN,
DNP
99
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Planned Parenthood of Houston
and Southeast Texas, Inc.
(covers the Planned Parenthood
of the Gulf Coast)
Houston, Texas
PLLCS Faro MD & Faro MD
Houston, Texas
Privy Oasis, LLC
Grapevine, Texas
Scott & White Memorial Hospital
MSN
RN, RN-BSN, MSN, DNP
RN-BSN, MSN, DNP
NP Only
(to 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”)
Temple, Texas
St. David’s Healthcare
Partnership, L.P., LLP (to include:
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.
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.
St. David’s Medical 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)
Austin, Texas
TCH Pediatric Associates, Inc.
d/b/a Texas Children’s Pediatric
Associates
Houston, Texas
Contract Company
Team Health West (THW)
Emergency Management of
Houston, LLC-Huntsville
Houston, Texas
Nurse Practitioner Students
Student: Must complete Exhibits A & B. Must have
yearly medical examination.
MSN, DNP
100
Must also have an agreement with Facility where
clinical experience will take place.
Agency Contact: Andrea Lowe-713-932-5803andrea_lowe@teamhealth.com
USA/Faculty: Provide Company and Preceptor with
an orientation to course objectives, schedule of
each student assignment, name of student, level of
academic preparation, length and dates of
assignment.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Texas Children’s Hospital
Houston, Texas
Texas Health Harris Methodist
Hospital Southwest Fort Worth
and Dr. Minh Q. Nghi
Fort Worth, Texas
Advanced Practice
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.
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.
Student: Must be tested annually for tuberculosis. If
working in the laboratory, students must have
documentation that Meningococcal vaccine has
been administered.
Texas Health Physicians Group
Dallas, Texas
MSN, DNP
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.
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 Coordinator-682-236-6187chekeshajackson@texashealth.org.
Students: Must complete Exhibit C-Confidentiality
Agreement. Must be aware of the Employee Health
policies and procedures of Facility.
The Heart Hospital Baylor Plano
Plano, Texas
DNP
101
USA/Faculty: See Exhibit A for clinical
requirements. Provide requested information at
least 10 days prior to clinical experience.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
The Woman’s Hospital of Texas
Houston, Texas
University Health System
San Antonio, Texas
MSN, DNP
MSN, DNP
Student: READ THOROUGHLY and complete
Exhibit B.
USA/Faculty: Complete Agency's AttestationExhibit C.
Student: Must complete Exhibits A & B.
*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 of Texas MD
Anderson Cancer Center
Houston, Texas
The University of Texas Medical
Branch at Galveston (UTMB
Health)
Galveston, Texas
MSN, DNP
University of Texas
Southwestern
Dallas, Texas
MSN, DNP
Provide names of students assigned to facility to
UTMB Contact: Kathy Angel 832-505-1026kangel@utmb.edu
University Medical Center of El
Paso (formerly R.E. Thomason
General Hospital)
El Paso, Texas
University of Texas Health
Science Center at Houston
Houston, Texas
Student: Must have basic health insurance
coverage. Must attend Health System Orientation.
USA must (if applicable) ensure that each Student
has secured and maintains all documentation
required for Student to enter and stay in the US.
Pediatrics
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.
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.
Department of Pediatrics Only-Must complete a
program agreement for additional programs.
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.
102
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 Michael
DeBakey Center
Houston, Texas
Valley Care Clinics and Heart
Clinics
Edinburg, Texas
Veterans Affairs North Texas
Medical Center
Dallas, Texas
William Beaumont Army Medical
Center
El Paso, Texas
RN-BSN, MSN, DNP
AGPNP, RN-BSNMSN, MSN,
Advanced Geropsych Assessment Older Adults
Practicum RN-BSN-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”.
FNP
Family Nurse Practitioner students
(Agreement applies to only one trainee at a time).
Utah
Central Utah Clinic
Provo, Utah
Family Healthcare
St. George, Utah
George E. Wahlen Department
of Veterans Affairs Medical
Center
Salt Lake City, Utah
IHC Health Services, Inc.
(Intermountain Healthcare)
Salt Lake City, Utah
BSN, RN-BSN, MSN,
DNP
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
BSN, MSN, DNP
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.
NP
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
103
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Ogden Clinic
Ogden, Utah
University of Utah Hospitals and
Clinics
Salt Lake City, Utah
BSN, RN-BSN, MSN,
DNP
MSN, DNP
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.
Agency contact is Jolene Guarniere, HR Specialist
& Student Coordinator, Ogden Clinic (801) 4753429 jolene.guarniere@ogdenclinic.com
Student will be responsible for health insurance.
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
Burbidge-milton.burbidge@hsc.utah.edu or Eddie
Decker-eddie.decker@hsc.utah.edu 801-213-3491.
Vermont
Fletcher Allen Health Care
Burlington, Vermont
MSN, DNP
Virginia
Carilion Clinic
Roanoke, Virginia
Centra Health
Lynchburg, Virginia
MSN, NP, DNP
MSN, DNP
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.
Students utilizing this agreement must submit a
copy of their own personal professional liability
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
104
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Children’s Hospital of the King’s
Daughters, Inc.
Norfolk, Virginia
NP
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.
Student: Will complete the student profile
attachment.
Agency Contact:Linda Grasmick
Nursing Practice and Education Department
757-668-8463
linda.grasmick@chkd.org
USA/Faculty: Provide adequate documentation
attesting to competency of each instructor, as
appropriate.
Dominion Hospital
Falls Church, Virginia
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 1stMarch 31st) as required by Hospital policy. Hospital
may, at its discretion, conduct an alcohol test on
Students.
Eastern Virginia Medical School
(EVMS) Department of OB/GYN
Norfolk, Virginia
MSN, DNP
Fairfax-Falls Church Community
Services Board
Fairfax, Virginia
MSN, DNP
Fort Belvoir Community Hospital
MSN, DNP
105
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.
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: Must complete Trainee Agreement.
Students will be required to have an ACCESS
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
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.
Fort Belvoir, Virginia
Kenner Army Health Clinic
MSN, DNP
(includes Wilkerson Pediatric Clinic)
Fort Lee, Virginia
LewisGale Medical Center
Graduate
(Renewal request sent, set to expire
7/7/2016)
Salem, Virginia
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-
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 Montgomery
Blacksburg, Virginia
LewisGale Physicians, LLC
Salem, Virginia
MSN, DNP
Graduate
Medicorp Health System (includes
Mary Washington Healthcare)
Fredericksburg, Virginia
Naval Health Clinic Quantico
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.
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.
USA Faculty: Complete the Documentation of
Compliance.
USA Faculty and Student POI:
Lila Pugh, Staffing Specialist, Human Resources,
lila.pugh@mwhc.com, (540) 741-1694
Graduate
(Renewal request sent, set to expire
7/1/2016)
Quantico, VA
Naval Medical Center
Portsmouth, Virginia
GRADUATE, NP
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: Must receive a copy of student’s
professional liability insurance for the file.
Sentara Healthcare System
106
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
(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)
Chesapeake, Virginia
University of Virginia Medical
Center and Transitional Care
Hospital
Charlottesville, Virginia
VA Medical Center of Salem
Salem, Virginia
Virginia Commonwealth
University Health System
(Medical College of Virginia)
Richmond, Virginia
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.
Nursing and Nurse
Practitioner Programs
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.
ADVANCED
EMERGENCY NP
Advanced Emergency NP’s only. Faculty please
complete the TQCVL form. Students must complete
the VA FORM10 and the Student Application.
Agency requesting to update
agreement.
Washington
Capital Medical Center
Olympia, Washington
Community HealthCare
Tacoma, Washington
DSHS Mental Health Division
(Western State Hospital)
Olympia, Washington
RN-BSN, MSN, DNP
Student must complete exhibits A & B.
BSN, RN-BSN, RNMSN
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
follow-up if student is ppd-positive. Must have
background record from the Washington State
Patrol and provide to facility.
Faculty: Provide Hospital with the name of the
Students selected to participate in the Program at
least fourteen (14) days before such Students
begins participation in the Program. Faculty and
Franciscan Health System (to
include: St. Francis Hospital, St.
107
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Students will conduct activities associated with this
Agreement in accordance with the Ethical and
Religious Directives for Catholic Health Care
Services, The Ethical & Religious Directives are
available at the following website:
http://www.usccb.org/bishops/directives.shtml.
Faculty and Students will conduct activities
associated with this Agreement in accordance with
the CHI Standards of Conduct attached as Exhibit
A. provide to Hospital an annual report evaluating
Program performance in the past year and
summarizing Program activities for the ensuing
year.
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
Student: Has undergone and passed a TB skin test,
and chest x-ray if applicable, within twelve (12)
months of participation in the Program has
demonstrated immunity to or has received
diphtheria, tetanus, rubella, rubeola, Hepatitis B
and any other vaccinations required by federal and
state law Has successfully completed TJC and
OSHA approved training in occupational exposure,
HIV/AIDS, universal precautions, body mechanics
and electrical and fire safety, HIPAA requirements
and requirements of applicable federal and state
laws or regulations. Student must pay all charges
resulting from treatment provided to them by facility
for emergency care, illness or injury. Student shall
secure and maintain general liability coverage with
limits of not less than $1,000,000 per occurrence
and $3,000,000 in the aggregate, and property
damage insurance of not less than $1,000,000.
Student(s) will be required to provide a copy of the
policy to the Hospital and School prior to beginning
the Program.
Franciscan Medical Group
Tacoma, Washington
Kadlec Regional Medical Center
Richland, Washington
PeaceHealth-St. Joseph Medical
Center
RN-BSN, MSN, DNP
RN, RN-BSN, MSN, DNP
MSN
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: 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.
MSN Students Only
Agreement for employees of facility only.
108
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Bellingham, Washington
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.
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
Seattle Children’s Hospital
Seattle, Washington
USA/Faculty: Will assure that students are
educated regarding universal precautions, bloodborne 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).
Swedish Health Services d/b/a
Swedish Medical Center
Seattle, Washington
VA Puget Sound Health Care
System
Seattle, Washington
Virginia Mason Medical Center
Seattle, Washington
SEATTLE CHILDREN EMPLOYEES ONLY
USA Faculty: Complete Letter of Agreement
and provide to Facility. Contact: Jackie Smith
-jacqueline.smith@seattlechildrens.org. See
Immunization and Health Requirements
document.
Students: Should obtain health and accident
insurance.
Nursing
NP
RN-BSN, RN-MSN
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.
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
bloodborne 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.
109
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Walla Walla General Hospital
Walla Walla, Washington
Western State Hospital—DSHS
Mental Health Division
Olympia, Washington
RN-BSN, MSN, DNP
Washington D.C
Children’s Hospital
Washington, D.C.
Georgetown University Hospital
Washington, D.C.
MSN, DNP
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.
West Virginia
Cabell Huntington Hospital
Huntington, West Virginia
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
VA Medical Center of
Huntington
Huntington, West Virginia
BSN, RN-BSN, RNMSN
MSN, DNP
Graduate Nursing
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.
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.
Wisconsin
Aspirus, Inc.
Wausau, Wisconsin
Aurora Medical Group, Inc.
Milwaukee, Wisconsin
GRADUATE
BSN, RN-BSN, RNMSN
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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.
To include all of AHC facilities. Faculty please see
Exhibit A-Program Memorandum
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Bellin Memorial Hospital, Inc.
Green Bay, Wisconsin
MSN, DNP
Bellin Psychiatric Center, Inc.
Green Bay Wisconsin
Children’s Hospital of Wisconsin
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
Milwaukee, 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
USA's attendance policy
~educational responsibilities of USA and facility as
it applies to agreement
Mercy Health System
Janesville, Wisconsin
Student: Exhibit A-Student Certification. Must
complete the Wisconsin Caregivers Background
Check and make available the results to the facility.
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.
GRADUATE
(renewal request sent, set to expire
5/31/2016)
RN-BSN, MSN, DNP
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 and Students please see exhibit 1 for
agency requirements per the addendum.
Meriter-Unity Point Health
Madison, Wisconsin
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
10-minute 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 Licensure Required RN & APRN. CNS
and Executive Nursing require RN Licensure.
Ministry Health Care, Inc.
Weston, Wisconsin
111
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
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.
Oneida Community Health
Center
Oneida, Wisconsin
ProHealth Care, Inc. (to include:
Waukesha Memorial Hospital,
Oconomowoc Memorial Hospital,
ProHealth Care Medical Assoc., Medical
Centers)
BSN, RN-BSN, RNMSN
MSN, DNP
Waukesha, Wisconsin
St. Vincent Hospital d/b/a
Prevea Health
(renewal request sent, set to expire
8/1/2016)
Green Bay, Wisconsin
ThedaCare, Inc.
Appleton, Wisconsin
MSN, DNP
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, Bloodborne pathogen.
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
screening.
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.
Wheaton Franciscan HealthcareSoutheast Wisconsin, Inc.
Milwaukee, Wisconsin
William S. Middleton Memorial
Veterans Hospital
MSN, DNP
112
Students and Faculty please see ALL detailed
requirements. Faculty, please see agency
attachments within PUB DOCs.
UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
May 9, 2016
Clinical Agency Affiliations and Locations
Programs
Agency Name
Agency Requirements
Covered
Madison, Wisoncsin
Zablocki VA Medical Center
Milwaukee, Wisconsin
Wyoming
Evanston Clinic Corp.
Evanston, Wyoming
MSN, DNP
USA/Faculty: Please see Addenda 1 & 2 regarding
Patient Care Duties. Report all appropriate
immunizations requested by Facility.
Student: Must complete Addendum #4 -Substance
Policy Consent Form and Addendum #5 Background Consent Form. Must have health
insurance during clinical rotation at facility.
Sheridan VAMC
Sheridan, Wyoming
MSN, DNP
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.
Nursing/Nurse Practitioner/MS
VA Medical Center of Cheyenne
Cheyenne, WY
BSN, RN-BSN, RNMSN
INTERNATIONAL AGENCIES
Germany
Landstuhl Regional Medical
Center
APO AE
MSN, DNP
Education Contact:
Robert L. Dennis, Jr.
Robert.l.dennis2.mil@mail.mil
Italy
US Naval Hospital
MSN, DNP
(renewal request sent, set to expire
8/1/2016)
113
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
Naples, Italy
Japan
18th Medical Group, Kadena Air
Base
Japan
35th Medical Group, Misawa
AFB
Japan
US Naval Hospital
Okinawa, Japan
US Naval Hospital
Yokosuka, Japan
Nurse Practitioner
Student must complete the Trainee Agreement
Addendum
Advanced Practice
Student must complete Trainee Agreement
Addendum
MSN, DNP
Nursing
US Virgin Islands
Gov. Juan F. Luis Hospital and
Medical Center
Christiansted, VI
BSN, RN-BSN, MSN, DNP
114
Student must sign Trainee Agreement Addendum
Student must complete Trainee Agreement
Addendum