Gwinnett Hospital System (GHS)
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Gwinnett Hospital System (GHS) Midlevel Requirements Quick Reference Guide
Process Form/Website Responsible Person Submit to
Initiation of Midlevel Process Form (See next section) Student L. Horst. Placement Allow > 60 days lead time. Assure MOU is W. Bolte & current/accurate Memorandum of Understanding (MOU) GHS & School J. Brooks Assures MD signs the Skills Part of MOU Student Wanda Bolte & List J. Brooks Drug/ Use either of these websites: Give GHS Background www.Advantagestudents.com or Student permission to Screening www.precheck.com view results. School GHS Website http://www.gwinnettmedicalcenter.org/GMCContent Student instructor/desig Orientation Page.aspx?nd=276 Do numbers 1 through 10 on this nee page. Note you may skip #6 Glucose Meter, if you will not regularly use our meters & #7 OR Protocol, if you will not be in the OR. Document LOG LOG on GHS Orientation web page. (Document Student, L. Horst -Placement orientation materials completed & placement instructor/designee details details.)
Obtain Badge Form located on GHS Orientation web page. Student L. Horst signs. Mid-Level Student Clinical Process Form For students in advance programs: nurse midwives, nurse anesthetists, nurse practitioners and physician assistants. INSTRUCTIONS Complete and submit this request form 60 days prior to start date to [email protected] .
Student Personal Information
Name Program
Address: City: Zip
Cell Phone: Email Address: Work Phone:
Employment Information
Employed at GMC? Job Title Department Yes (Complete next 2 columns.)
No (Go to next section.)
Educational Information
Name of School: Program: Semester (1st, 2nd etc):
Clinical Start Date: Clinical End Date
Department or area requested for Clinical Experience:
Contact person at school including: Name Title Address Phone Number Fax Number Email address Contact person at physician office including: Name Title Name of Practice Address Phone Number Fax Number Email address Physician that will be accountable: Name Physician, check one below and sign here: ______
Physician employed by GMC Yes No
(All information on form must be entered for contract to be generated and for student placement processing to begin)