• Student Training Pharmacy, MD, PAs, CRNA & Nursing

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Hazardous Drug Attestation

  • I understand working with or near hazardous drugs in a health care setting may cause skin rashes, infertility, miscarriage, birth defects and possible leukemia or other cancers. I understand that Williamson Health pharmacy and nursing maintains detailed policies and procedures on the proper storage, handling, transport, and disposal of hazardous drugs. Williamson Health pharmacy and nursing has put in place a variety of administrative, engineering, and work practice controls to reduce the risk of occupational exposure to hazardous drugs. I understand Williamson Health policies and procedures will be reviewed on a regular basis and the policies and procedures seek to reflect information, standards, and regulations from relevant local, state, and federal regulatory bodies as well as practice standards from professional associations. I have been provided with training that reflects the policies and procedures on hazardous drugs, including listing, handling, PPE, proper use of devices, response to exposure, spill management, and disposal of HD and have been afforded the opportunity to ask questions.   After completion of training, I have been required to take and successfully pass testing and competency.  Retraining and competency evaluation will occur annually.  I received and successfully completed this training prior to performing any activity associated with hazardous drugs.  I understand Williamson Health policies and procedures and agree to abide by them at all times.  I also agree that I will immediately seek out a unit director or direct supervisor should a question occur during clinical activities. I acknowledge that failure to follow the established policies and procedures may put me at risk of exposure to hazardous substances which can lead to acute effects such as skin rashes and/or chronic effects such as adverse reproductive events. *
  • Signature*
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Flu Shot Attestation

  • Please indicate below your flu shot status (November 1st-March 30th)*

  • Parking Form

  • Student Parking Information- put NA if you are not driving yourself*
  • Print the parking form for your reference:
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Temporary or permanent residence of greater than or equal to 1 month in a country with high TB rate. Any country other than the United States, Australia, New Zealand, Northern or Western Europe. *
  • Current or planned immunosuppression. Including human immunodeficiency virus (HIV) infection, organ transplant recipient, treatment with a TNF-alpha antagonist (e.g. infliximab, etanercept, or other), chronic steroids (equivalent of prednisone greater or equal to 15mg/day for greater or equal to 1 month) or other immunosuppressive medication.*
  • Close contact with someone who has had infectious TB disease since the last TB test.*
  • Productive, persistent cough lasting 2-3 weeks in duration?*
  • Blood in sputum?*
  • Night Sweats?*
  • Weight loss not caused by dieting?*
  • Fatigues, tires easily?*
  • Unexplained fever or shortness of breath?*
  • My signature below indicates that my TB Risk Assessment is accurate:*
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: