Nursing Instructor: Overview
Orientation & Annual Requirements
Instructor Name: ____________________________ Last 4 SS#_______________
Name of School: _____________________________ NL login: ________________
Instructor Phone & Email: _____________________________________________
*(Give a copy of this overview sheet and the documents with an asterisk (*) to the LR Coordinator.)
Requirement
NEW
Annual
To Complete
Requirements
Requirements
1. Drug Screen
2. Background Check
Drug Screen
Background Check
NA
NA
Prior to Expiration:
3. Proof of RN Licensure
RN License
RN License
4. CPR Certification
CPR*
CPR*
Instructors for Clinical Groups Complete Computer Based Learning and Skills Day Requirements
Computer Based Learning (CBL) Requirements are completed in
NetLearning (NL). You will have a NL login ID assigned to you.
The CBLs are accessed on www.gwinnettmedicalcenter.org. Click
on “Programs and Classes”, Community, Student Experiences, “Step
3: Orientation”. On this page review the materials under
“FACULTY/Instructors”. The Web link and directions for NL are
also found on this website.
Proceed to complete the CBL NetLearning bundles.
 As a new instructor you will complete “New Nursing
Instructor Orientation CBLs”.
 Annually thereafter, to remain current, you will
complete:
 “Instructor Annual CBLs”;
 “Instructor Update CBLs”; and
 Update yourself on your unit as appropriate and
sign the Annual Unit Skills and Processes
Update Acknowledgement Statements. (Give
this form to the student placement coordinator.)
The following are signed initially and attached to this document:
 Confidentiality Agreement part of (IPST).
 Sign Acknowledgment of GMC Code of Conduct Form.
 MRI Form.
Orientation CBLS
Annual CBLs
Update CBLs
Acknowledgement
Statements Signed*
Sign Agreement*
Sign Form*
Sign MRI Form*
Continued On Next Page
NA
NA
NA
Requirement
To Complete
NEW
Requirements
Annual
Requirements
New Instructors attend Skills Day:
Complete computer based learning (CBL) modules in NetLearning
prior to attending Skills Day.

Attend Skills Day at the GHS Resource Center
between 7:30am and 10:00am on one of the following dates:
11/16; 12/21.
Note: New Instructors: Demonstrate Glucose Meter competency
again at 6-months and may be done on the unit.
Skills Validation
Sheet*
NA
Four (4) hours of Precepted Time on the Unit with
manager/designee – some units may require you to spend more time.
Preceptor – sign
here_____________
________________
Admin RX Class
Other:
Attend additional classes:
You will get this sheet at
Skills Day to take station
to station.
Only if new to Unit
Preceptor – sign
here____________
_______________
Admin RX Class
Other:
ID BADGE and Parking
ID from the school REQUIRED at all times.
GMC INSTRUCTOR ID/PARKING ACCESS
Badge REQUIRED at all times.


ID/Parking Badge
&
Dress Code


Complete the ID/Badge form attached to
this document.
The Student Placement Coordinator will
sign the document and you will take to
Security to obtain your badge.
The badge will give you access to parking
and the units.
Once you have your badge you may sign
the Parking Form for your students and get
their badges. (They will pay a $5
refundable deposit for their badge.)
Wear school uniform. Your department will direct
you to follow the GMC Dress and Appearance
Policy 300-505.
Non-Associate Confidentiality Agreement
I understand Gwinnett Health System (GHS) has a legal and ethical responsibility to safeguard the
privacy of all patients and to protect the confidentiality of their health information.
As a condition of my affiliation with GHS, I agree to maintain the privacy and confidentiality of
any patient identifiable information that I may intentionally or unintentionally become aware of as
result of my affiliation with GHS.
Signature
Printed Name
Date
____________________________________
Organization Represented (school, company, etc.)
Receipt and Acknowledgement of
Gwinnett Hospital System, Inc. Code of Conduct
By signing below:
 I acknowledge that I have received my personal copy of the Gwinnett
Hospital System, Inc. (GHS) Code of Conduct.
 I understand that I am responsible for knowing and following the
Code of Conduct as a condition of my continued affiliation with
GHS.
 I also understand that I am responsible for reporting any actual or
perceived violations of the Code of Conduct, including any
departmental policies, and state or federal law to the appropriate
management representative:
Compliance Hotline 888-696-9881
Chief Compliance and Privacy Officer 678-312-4388
Associate Relations Director 678-312-2642
Risk Management Director 678-312-3264
Information Security Officer 678-312-4717
Printed Name: _________________________________________
Signature: ____________________________________________
Date: ________________________________________________
Your affiliation with GHS:
 Associate–Department: ___________________________
 Medical or Affiliate Staff – Practice Name:
_____________________________________________________
 Volunteer – Facility: ____________________________________
 Contractor or Agency – Company Name:____________________
 Other ________________________________________________
Revised January 2009
CLINICAL SHADOWING EXPERIENCE
Magnetic Resonance Imaging (MRI) Form
All MRI suites maintain a safe environment by: restricting access to all MRI work areas; requiring modified GMC
identification badges for associates who may not safely enter the MRI area; and screening “all” associates, patients, and
family members prior to entering the MRI suite for pacemakers, aneurysm clips, permanent tattoos, body piercing,
hemostats, pagers, and more. Students or faculty who have experiences in the MRI area need to be thoroughly screened
and cleared to enter the area using the MRI Safety questions below. Please circle your answers and then sign this
form below.
MRI Safety Questions
1. Have you ever been hit in the face with a piece of metal (including metal shavings, slivers, rust, BB’s or
YES
NO
2. Have you ever worked as a machinist or welder?
YES
NO
3. Have you ever had metal removed from you eye?
YES
NO
4. Do you have any metal in your body from an accident (including pencil points, shrapnel)?
YES
NO
5. Have you ever had eye surgery (other than LASIK surgery)?
YES
NO
6. Do you have any surgically implanted metal (including an intrauterine device, catheters, tubes, stints, or
YES
NO
7. Do you have or have you ever had a pacemaker, pacemaker wires, defibrillator or cardiac valve prosthesis?
YES
NO
8. Do you have a brain/aneurysm clip?
YES
NO
9. Do you have an eye/ear implant or hearing aid?
YES
NO
10. Do you have an electrical stimulator for nerves or bones?
YES
NO
bullets)?
valves)?
I have answered the above questions candidly. My signature below validates the above contents.
_____________________
___________________________________________________
Date
Signature of Parent, Guardian, Or Participant (if over 18 years of age)
STUDENT/Instructor ID CARD ACCESS CONTROL
Student/Instructor: Please complete this form and give it to your instructor along with a $5
refundable deposit to receive a GHS Student ID badge.
Instructor: Please submit the completed forms and deposits to the Public Safety Office at
Gwinnett Medical Center (extension 4057 or 4590). Student ID badges will then be issued. When
ID badges are returned to Public Safety, refunds will be issued.
Please print the following information:
Student’s Name:
__________________________________________________________________
Address:
_________________________________________________________________________
Phone #: _________________________ School: _______________________________________
Semester:
Start Date: ________________________End Date:__________________________
(To be filled out by the class instructor):
Instructor’s Name: ______________________________________ Phone: ____________________
Authorized Signature: ______________________________________
Parking Lot:
_____GMC _____GWP ____BOTH
Vehicle Information: Year ______
____________________________
Make (Ford, Chevy, Honda, etc.)
Model (Taurus, Malibu, Accord, etc.) ________________
License/Tag # _________________
$5 Deposit _____
Color _______________
State _____________
ID Card # ____
Directions: Complete this Form Annually (Turn in to student placement coordinator.)
Instructor
Name:
Date:
PLEASE PRINT
School:
NURSING INSTRUCTOR Annual
Unit Skills and Processes Update
Acknowledgement Statements
Print this document. Circle your response to each statement. Erase any stray marks. Sign at
the bottom and then turn this signed document in to the student placement coordinator, Linda
Horst in Learning Resources.
1. I acknowledge that I have met with the unit educator/designee on the unit I will
supervise and instruct students to review and update myself on skills, processes, or
changes I will need to assure safe quality patient care.
Yes
2. I acknowledge that, in my role as an instructor, I can function safely and
appropriately on the unit I have been assigned to.
Yes
3. I know how and where to get my questions answered.
Yes
Nursing Instructor Signature:
________________________________/___________________________
Sign
Print Name
Date Signed: ____/____/____