Gwinnett Hospital System (GHS) s1
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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 List Part of MOU Student Wanda Bolte & J. Brooks Drug/ Background Use either of these websites: Give GHS Screening www.Advantagestudents.com or Student permission to www.precheck.com view results. School GHS Website http://www.gwinnettmedicalcenter.org/GMCContent Student instructor/desig Orientation Page.aspx?nd=276 Follow the directions to complete nee all required materials on this page and refer to “Student Requirements 2013” document. Document LOG LOG on GHS Orientation web page. (Document Student, L. Horst -Placement details orientation materials completed & placement instructor/designee details.) Attach signed copies of the Board of Regents or Non-Board of Regents documents as explained in item #1 on this page.
Obtain Badge Refer to “Student Requirements 2013” document for Student L. Horst detailed information. Page 2 of 3
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 Page 3 of 3
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)