Student Training Pharmacy & Nursing

Student Training (General)
Name (Legal name)*

First NameLast Name
Program of Study
(Physician Assistant, PT, OT, etc.)
Email*
example@example.com
Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.

Parking Form
Clinical Student Parking Information- put NA if you are not driving yourself*
Print the parking form for your reference:
Student Emergency Contact Information

OR scan the QR code below

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?*
Blood in sputum?*
Night Sweats?*
Weight loss not caused by dieting?*
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*

MonthDayYear
Date
If you did NOT get the flu vaccine, please complete this form
Scan the QR code or click the link below to complete required training:

(Must be completed by ALL Students & Instructors)
Use this password to login for required regulatory training: WHStudent26
Regulatory training link Password is: WHStudent26

https://rise.articulate.com/share/4Kn3_Dw-Qjvg_1tfZczOWKGOPFK9RjaP
Download the Certificates (PDF Format, no pics/images) for required training here: *

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Student Training (General)

Parking Form

Scan the QR code or click the link below to complete required training: