THE CENTER FOR NURSING EXCELLENCE 
1620 TREMONT STREET BOSTON, MA 02120
APPLICATION FOR PRIVILEGES
FOR FIRST TIME APPLICANTS
Name:
Date of Birth:
Last 4 digits of SS#:
Email Address:
Phone Number:
Mailing Address:
Affiliation (not BWH):
Clinical Area of Practice at BWH:
Expiration Date:
RN License Number:
Agency for Malpractice Insurance:
Please be sure to attach a copy of your policy with coverage limits of at least $1 million
Expiration Date:
Policy Number:
BLS or CPR Expiration: (or)
CPR with AED Return Demonstration Date:
If you are not currently BLS certified, you will need to arrange for return demonstration of CPR and AED Skills
prior to patient or patient record contact. Please visit our website for available validation sessions.
Previous Employment at BWH
Current Employee at Partners HealthCare
Current Employee at BWH
If so, please enter Direct Supervisors name at BWH
Yes
Yes
Yes
No
No
No
OUTSIDE AGENCY EMPLOYER INFORMATION
For Liaisons, please list your employer
For School of Nursing / Clinical Instructors, please list the School of Nursing you will be working for
Employer / Affiliation:
Address:
Phone Number:
Job Title:
Staff Privileges at Other
Institutions:
If yes:
(1) Organization Name:
Address:
Phone Number
(2) Organization Name:
Address:
Phone Number
Date of Employment:
Yes
No
THE CENTER FOR NURSING EXCELLENCE 
1620 TREMONT STREET BOSTON, MA 02120
Purpose of Staff Privileges
(Check all that apply):
Clinical Practice Area (Check
all that apply)
Access to Medical Records
Case Management
Consultation
Direct Patient Care
Faculty/School of Nursing/Clinical Instructor
Nursing Research (must provide abstract of project/proposal or Human
Subjects Committee Approval)
Telephonic Reviewer
Other (please Specify) _________________
I will require a BWH ID to access BEH Facilities
Ambulatory Services
Antepartum
Bone Marrow Transplant
Burn Trauma
ICU
Cardiac Care
Clinical Research Center
ED
General Medicine
General Surgery
I.V. Therapy/PICC Lines
LBR (Labor, Birth, Recovery)
Medical ICU
Neuroscience
Normal Newborn
OR
Orthopedics Post
Anesthesia Care Unit
Post Partum
Renal
Thoracic ICU
Other (please specify):_______________
If Faculty, please specify Unit:
I understand that I will be required to complete compliance training annually through HealthStream and other
trainings as required.
SIGNATURE
Date
DIRECT SUPERVISORS SIGNATURE (REQUIRED FOR BWH AND NON BWH EMPLOYEES)
Endorsement of organizational representative of requesting institution.
I verify the person seeking privileges is qualified, capable, and prepared to perform the services for which
they are seeking privileges and that a National County Background Check has been performed and “no
record” has been returned.
SIGNATURE OF OUTSIDE AGENCY SUPERVISOR
TYPE NAME
EMAIL ADDRESSS
Date
PHONE NUMBER
FOR BWH / PARTNERS EMPLOYEES ONLY
Endorsement of BWH / Partners immediate Supervisor. I verify the person seeking privileges at BWH is an
employee in good standing.
SIGNATURE OF BWH / PARTNERS SUPERVISOR
TYPE NAME
EMAIL ADDRESSS
Date
PHONE NUMBER