Student Training EMS
Name (legal name)
*
First Name
Last Name
Email
*
example@example.com
Student Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 1
*
First Name
Last Name
Emergency Contact 1 Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 2
*
First Name
Last Name
Emergency Contact 2 Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Flu Shot Attestation
My clinical rotation falls outside of flu season after March 30th and before November 1st.
*
I have received a flu shot and provided the documentation to my school.
I have not received a flu shot and agree to war a surgical mask in all WH facilities during by clinical rotation.
My clinical rotation falls outside of flu season after March 30th and before November 1st.
Download the Certificate for required regulatory training here:
*
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Parking Form
Clinical Student Parking Information- put NA if you are not driving yourself
*
Print the parking form for your reference:
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TB Risk Assessment & Symptom Evaluation- please type your full name
*
Temporary or permanent residence of greater than or equal to 1 month in a country with high TB rate. Any country other that 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?
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Blood in sputum?
*
Night Sweats?
*
Weight loss not caused by dieting?
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Fatigues, tires easily?
*
Unexplained fever or shortness of breath?
*
If "Yes" to any question please explain:
My signature below indicates that my TB Risk Assessment is accurate:
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Fit Testing
Review the acceptable and unacceptable types of facial hair- This form may be printed for your reference.
Upload completed Respiratory Questionnaire here:
*
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Respiratory Protection Questionnaire EMS Student
Legal Name
*
First Name
Last Name
Height:
*
Weight:
*
Age:
*
Have you worn a respirator in the past?
*
Yes
No
Don't know
List types worn below:
Select any problems experienced when wearing a respirator in the past:
*
Eye Irritation
Skin allergies or rashes from mask
Anxiety
General weakness or fatigue
None
Other
If other explain:
Do you smoke tobacco or have you smoked tobacco in the past?
*
Yes
No
Select any of the following conditions you have had:
*
Seizures
Diabetes
Allergic reactions that interfere with your breathing
Claustrophobia
None
Select any of pulmonary conditions you have had:
*
Asbestosis
Asthma
Chronic Bronchitis
Emphysema
Pneumonia
TB
Silicosis
Pneumothorax
Lung Cancer
Broken Rids
None
List any other chest injuries, surgeries, or lung problems you have been told about:
Check any current pulmonary symptoms you have:
*
Shortness of breath
Shortness of breath when walking fast on level ground or uphill
Shortness of breath when walking on level ground at ordinary pace
Shortness of breath when washing or dressing self
Shortness of breath that interferes with your job
Coughing that produces phlegm (thick sputum)
Coughing that wakes you early in the morning
Coughing that occurs mostly when you are lying down
Coughing up blood in the last month
Wheezing
Wheezing that interferes with your job
Chest pain when you breathe in deeply
None
Other
If other explain:
Have you ever had any of the following cardiovascular or heart problems?
*
Heart Attack
Stroke
Angina
Heart failure
Heart palpitations
High blood pressure
Irregular heart beat
Leg or feet swelling
Frequent pain or chest tightness
Pain or chest tightness during physical activity
Pain or tightness in chest that interferes with job
Heart missing beat or skipping
Heartburn or indigestion that is related to eating
None
Other heart problems you have experienced:
Select any condition/s you currently take medication for:
*
Breathing or lung problems
Heart trouble
Blood Pressure
Seizures
None
Signature
Date:
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