ADDENDUM A
(Page 1 of 3)
Bronson Contract for Training 2015-2016
Report of Student Minimum Work Requirement1
Specific Bronson affiliates will be referred to as: Bronson Methodist Hospital, Kalamazoo, Michigan as “BMH”; Bronson Lakeview Hospital, Paw Paw,
Michigan as “BLH”; Bronson Battle Creek Hospital, Battle Creek, Michigan as “BBCH”.
Faculty or School Administration:
 Complete all the requested information
 Return to the Bronson Facility’s Department Placement Coordinator or BBCH Human Resources before the placement begins.
School/Course:
Term/Semester:
Bronson Facility and Unit/Department where STUDENTS will be based:
Placement Information:
Start Date:
End Date:
Days of the week:
Start Time:
End Time:
Clinical Faculty:
Faculty Contact information for this semester:
Year:
Year:
Faculty or School Administration:
 Complete the following chart information and return to Bronson Education Services or the Clinical Placement Coordinator for the area. Use
additional pages as necessary.
 The Clinical Placement Coordinator Unit/Dept is Sarah Barker, Education Services 269-341-8917.
Student Name
Type or Print Legibility
Nationwide
Current TB BackNegative
ground
Screen or check
Treated
completed.
(Within 365 See next
days)
page for
explanation.
Current immunizations or
immunity:
MMR (Measles, Mumps,
Rubella), current Tdap
(Tetanus, diphtheria,
Verification of
pertussis), Varicella, Seasonal HIPAA Training
Influenza, Hepatitis B (or
declination), Other
Immunizations as required by
other regulatory agencies.
On Site Faculty
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
1 See the information for Student Minimum Requirements on the following pages.
Respirator
Questionnaire
Orientation to Bronson
Complete
Negative
Customer Service,
(for PAPR)
Drug
Safety, Security, P&P &
Testing Current
Unit-specific Minimum
(Determined by
(Within BLS
Requirements
the job
365
Faculty provides unless other
requirement
days)
arrangements are made.
where the student
is placed)
Powered Air
Purifying
Respirators
PAPR
Bronson IT
System
Authorization
as needed.
ADDENDUM A
(Page 2 of 3)
Verification that requirements for STUDENTS at BRONSON have been met is reported using the table from Addendum A. Addendum A is
to be on file with the Bronson Facility Placement Coordinator for the unit or department, or for BBCH with their Human Resources Department
BEFORE STUDENTS begin learning activities. Course schedule with specific times STUDENTS will present should be posted and cleared with the
Placement Coordinator and the Department where the STUDENTS will be placed. If there is more than one clinical group here for a semester, provide
a separate list for each group. Use as many pages of this form as needed to provide each STUDENT’S information. These requirements may be
modified based on patient safety or regulatory changes.
Information about Student Minimum Requirements
Current TB Negative Screen or Treated: Must be within 365 days. Documentation is on SCHOOL’s records that the STUDENT and SCHOOL
representative(s) are free of transmissible tuberculosis by:
(i)
An annual Mantoux tuberculosis skin test, the latest being administered within the last 365 days and yielding a negative result. STUDENT
and SCHOOL representatives must maintain their annual TB skin test schedule while at BRONSON; or
(ii)
A physician’s documentation that the STUDENT and SCHOOL representative(s) are free of transmissible tuberculosis (by chest x-ray or
prophylactic treatment).
Nation-wide Back-ground check: Consult with Bronson about ‘positive’ results or questions. The SCHOOL representative will consult with
BRONSON about any ‘positive’ background check results. BRONSON’s decision to permit placement are based on individual situations. Guidelines for
our decision making can be provided. Other background checks may be required based on the unit of placement. Specific units/departments or
agencies may have additional requirements. Current guidelines are Michigan Workforce Background Check Legal Guide.
http://www.lssu.edu/nursing/documents/LegalGuideforCriminalBackgroundChecks.pdf
Current Immunizations or Immunity: MMR (Measles, Mumps, Rubella), current Tdap (Tetanus, diphtheria, pertussis), Varicella,
Seasonal Influenza, Hepatitis B (or declination), Other Immunization as required regulatory agencies. Acceptable documentation
immunity to measles, mumps and rubella is from either proof of immunity or documented administration of the MMR vaccine schedule.
If the STUDENT and SCHOOL representative(s) have reasonably anticipated occupational exposure to blood, body fluids, or blood borne pathogens,
the STUDENT and SCHOOL representative(s) shall either:
(i)
Provide documentation of having completed the three-dose hepatitis B vaccine series; or
(ii)
Provide documentation of immunity to Hepatitis B; or
(iii)
Receive the Hepatitis B vaccine series with the first dose given prior to placement; or
(iv)
Sign the Hepatitis B Vaccine Declination Statement.
BRONSON’s ProHealth can provide the above immunizations or lab tests at the STUDENT/SCHOOL’s expense.
HIPAA and Confidentiality: The School provides healthcare HIPAA training that meets BRONSON’s standards and maintains record of STUDENTS’
training and agreement to treat all information as confidential in accordance with these standards. A copy of BRONSON’s HIPAA and confidentiality
training can be made available to the SCHOOL. BRONSON’s Code of Conduct is posted at www.bronsonhealth.com. Search Code of Conduct.
Powered Air Purifying Respirators (PAPR): Need for the Powered Air Purifying Respirator (PAPR) is determined by the job requirement for the
department of STUDENT placement. All inpatient units and departments require the PAPR. Consult with the Bronson Placement Coordinator if there
are questions. Education on the PAPR can be provided by the Bronson Placement Coordinator.
Respirator Questionnaire Complete: This form is not a new requirement and has been required for the N-95 mask. It is required for the Powered
Air Purifying Respirators also.
(for PAPR)
ADDENDUM A
(Page 3 of 3)
Negative Drug Testing: Must be within 365 days. BRONSON’s ProHealth can provide the drug screening at STUDENT/SCHOOL’s expense. BBCH
requires an 11 Panel, Non-regulated; all other BRONSON facilities require a 10 Panel non-regulated. Specific units/departments may have additional
requirements.
Orientation to BRONSON: Safety, Security, Customer Service, Policy and Procedure and Unit-specific minimum requirements.
STUDENT is to be oriented to any BRONSON facility where they are placed. The orientation process is determined by Faculty and the
Placement Coordinator. Student orientation includes but is not limited to: BRONSON Customer Service Standards, Safety and Security, including
parking, HIPAA, Infection Control, Team Communication, Unit specific: Emergency Management, and Fire Safety. Guidelines for orientation are
posted at www.bronsonhealth.com.
Search Student Experience. On-site faculty maintains annual documentation of review of minimum
requirements. Available through Education Services/NetLearning.
BRONSON ID BADGE: All STUDENTS must wear a Bronson Picture ID Badge identifying their role. The STUDENT and SCHOOL representative(s) will
procure a temporary BRONSON identification badge prior to beginning the learning experience. This badge must be worn while on BRONSON
premises when the STUDENT is in the student role. For BMH: Badge authorization forms are provided by the sponsoring department. The
Bronson Placement Coordinator or HR can provide a copy of the authorization form for faculty to return with the required information. For BBCH
placements, contact the Human Resources Department at 269-245-8060.
BRONSON SYSTEM APPLICATIONS: BRONSON system applications that support education goals are provided for STUDENTS and instructors.
Faculty/Students/Bronson Educator or Placement Coordinator work together to complete the system access authorization. For BMH, Forms and
Process are available with the sponsoring department placement coordinator. STUDENTS and faculty must comply with the rules of use for BRONSON
processes and systems. Noncompliance may result in termination of this Agreement. BMH IT System Authorization is completed online. The online
link is available at www.broronsonhealth.com or contact the Clinical Placement Coordinator for an alternate link if there are problems. IT system
access at BBCH is determined and arranged with Human Resources. Contact 269-245-8060. Allow a minimum of 1-2 weeks to process access to any
system accounts.
STUDENT PROJECTS: STUDENT projects may be subject to review by BRONSON’s Research Committee and may require an Internal Review Board
(IRB) review. When there are questions, the Research Committee will be included in decision-making about individual projects.
Verification of this information is current, on file and available from SCHOOL records for each individual STUDENT listed.
Faculty Signature (Electronic signatures are accepted):
When completed, return to:
Sarah Barker MSN RN-BC, Staff Development Specialist
Bronson Hospital
Education Services
601 John St
Kalamazoo, MI 49007
Email: BarkersA@bronsonhg.org
Phone: 269 341-8917 Fax: 269-341-6833
School Administration’s Main Contact Number: