Submit To: Center For Professional Practice of Nursing
Broadway Building, Suite 1630
Page 1 of 1
AUTHORIZATION FOR SHORT-TERM ROTATION TO UCDHS (PCS)
WHERE NO TRAINING AGREEMENT EXISTS
Student Name: (First)
Course Title:
Academic Institution:
Sponsoring Department at UCDHS :
Rotation Start Date:
License Number (if applicable):
Health Clearance Documentation (documents kept by
CPPN)
(Last)
(Middle)
Social Security No.:
Degree sought (BSN, MSN, PhD):
Rotation End Date:
Expiration Date:
Signed Confidentiality Agreement:
[agreement kept by Center for Professional Practice of
Nursing (CPPN) (“CNE)]
Training Institution: UC Davis (UCDHS)
Anticipated Graduation Date (mm/dd/yyyy):

UCDHS has reviewed the credentials of the Student and has accepted her/him for an elective rotation. The privileges
to be granted to the Student are listed in course descriptions and PCS Student Affiliation Requirements Policy 2610,
which will be provided to the Student by CPPN and/or the Nursing School/Training Institution.

Academic Institution and the Student shall assure all documentation requested in PCS Policy 2610 is provided as
directed and shall comply with all requirements listed therein, as applicable.

Academic Institution warrants no disciplinary actions have been taken or are pending against the Student and
the Student has not been involved in any claims, actions or formal complaints related to patient care.

The Student shall perform the duties and responsibilities listed in the Student Skill Set/Handbook and PCS Policy
2610. During the rotation, the Student shall comply with UCDHS policies and procedures.

Academic Institution or the Student shall provide professional liability coverage applicable during the rotation and
shall provide evidence of coverage to UCDHS before the rotation begins.

UCDHS and Academic Institution each agree to defend, indemnify and hold each other and each other’s respective
officers, agents, and employees, harmless from and against any and all claims liability, loss, expense, including
reasonable attorneys’ fees, or claims for injury or damages arising out of the performance of the rotation, but only in
proportion to and to the extent such liability, loss, expense, attorneys’ fees, or claims for injury or damages are
caused by or result from the negligent or intentional acts or omissions of the indemnifying party, its officers, agents,
or employees.

Student shall register with the UCDHS CPPN office prior to reporting to the clinical service.

During the rotation, the Student shall be considered neither a student nor employee of UCDHS.

Upon completion of this rotation, if not a UCDMC employee, the Student shall return UCDMC photo-ID badge,
University keys, and any other University property loaned to the Student during the rotation.
APPROVED AND AGREED
UCDHS (Training Institution)
Academic Institution
Signature
Manager/Director – Sponsoring Department, Training Institution
Date:
Rotating Student’s Signature
Email Address:
Date:
Kathleen Guiney, R.N., M.S., M.N., Nurse Educator, Center for
Professional Practice of Nursing
Authorized Official, Training Institution
Date:
Signature
Title:
Authorized Official, Academic Institution
Date:
Form completed by:
Telephone:
Submit To: Center For Professional Practice of Nursing
Broadway Building, Suite 1630
AUTHORIZATION FOR ROTATION CHECK SHEET
A.
DOCUMENTS TO BE SUBMITTED TO CENTER FOR Professional Practice of Nursing
Authorization for Rotation Forms must be submitted to the Center for Professional Practice of Nursing Office at least10 days
prior to the start of the rotation.
 Authorization for Rotation Form signed and dated by the Student, UCDHS Departmental Manger/Director of sponsoring
department, and Program Director from Academic Institution.
 Copy of insurance certificate and/or letter of indemnity.
 Student meets contractual employee requirements, to include health clearance, signed confidentiality agreements,
environment of care updates, and BLS card as outlined in PCS policy 2610.
 Background check.
B.
DOCUMENTS TO BE RETAINED BY CENTER FOR NURSING EDUCATION
 Listing of Duties, Responsibilities and Privileges.
 License number and expiration date (include data in authorization form).
 CPR Certificate.
 Health Clearance Documentation Signed Confidentiality Agreement.