Clinical Agency Affiliation List

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered 1st Operations Medical Group MSN, DNP, Post Student must complete Attachment 1 Graduate Certificate, Hurlburt Field, Florida MSN to DNP 2D Medical Group MSN Student must complete the Trainee Agreement Addendum Barksdale AFB, Louisiana 3HC Home Health & Hospice Care Undergraduate and Graduate Students Goldsboro, North Carolina 4th Medical Group Seymour Johnson AFB, North Carolina 5th Medical Group-Minot AFB MSN and DNP Student must complete Trainee Addendum. Student may utilize agreement for a period of no Minot AFB, North Dakota more than 2 years at a time. 18th Medical Group, Kadena Air Nurse Practitioner Student must complete the Trainee Agreement Addendum Base Japan 21st Medical Group, Peterson Air Executive Nursing Executive Nursing Admin DNP ONLY Admin DNP ONLY Force Base Student must complete Attachment 1 Colorado 35th Medical Group, Misawa AFB Advanced Practice Student must complete Trainee Agreement Addendum Japan 48th Medical Group, Executive Nsg Please contact the following for interest in this site. Admin DNP ONY RAF ALANE C. GARLISI, Lt Col, USAF, NC Lakenhealth , UK Education and Training Flight Commander 48th Medical Group, RAF Lakenheath, UK [email protected]

Student must complete the Trainee Agreement. 99th Medical Group, Mike Advanced Practice Student must complete Trainee Agreement Addendum O’Callaghan Federal Hospital Nellis Air Force Base, Nevada Renewal in process-set to expire on 9/9/2018

354th Medical Group, Eielson, Nurse Practitioner Student: Must complete the Trainee Agreement Addendum, provided by the facility. AFB, AK Alaska (Pediatrics Department Only) 377th Medical Group, Kirtland AFB Student must complete and sign the Trainee Agreement Addendum. While utilizing this New Mexico agreement, students are prohibited from engaging in off-duty employment at USAF MTF. 436th Medical Group Women’s Health Student must complete the Trainee Agreement Nurse Practitioner Addendum Dover Air Force Base ONLY Dover, Delaware 509th Medical Group RN-BSN, MSN, Student must complete Trainee Agreement Addendum Whiteman AFB, Missouri DNP 673rd Medical Group, Join Base, RN-BSN, MSN, Attachment 1 and 2 for Trainee Agreement Addendum Elmendorf-Richardson DNP

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered JBER, Alaska

Agency Name Programs Agency Requirements Covered Abrom Kaplan Memorial Hospital Undergraduate and Graduate Nursing Kaplan, Louisiana Students Access Community Health Network Graduate Nursing USA/Faculty: Please see Exhibit A for all Facility Programs Sites. Chicago, IL (see Exhibit A for complete Student: Must obtain comprehensive health lists of affiliates covered by agreement) insurance. Shall provide to Agency evidence that they have met all requirements of CPR certification, hepatitis B vaccination, and OSHA compliance for prevention of transmission of blood borne pathogens and TB before being placed in the Program. A criminal background check and drug screen, as specified in Exhibit B, and as required by and acceptable to Agency, are required of each Participant prior to being placed in the Program.

Each student prior to his/her arrival at the Agency Site are required to:

(i) Follow the administrative policies, standards, and practices of Agency; and

(ii) Obtain medical care at his/her own expense for any injuries or illnesses sustained as a direct or indirect result of his/her participation in the Program; and

(iii) Provide his/her own transportation and living arrangements; and

(iv) Report to the assigned Agency Site on time and follow all established regulations of Agency during the regularly scheduled operating hours of the Agency Site; and

(v) Conform to the standards and practices established by USA while participating in the Program; and

(vi) Meet the personal, ethical and professional standards required of employees of Agency and conduct themselves at all times consistent with the applicable professional Code of Ethics and the applicable standards of the Joint Commission and/or other relevant accrediting or regulatory bodies; and

(vii) Obtain prior written approval of Agency and AFFILIATE before publishing any material relating to the Program. Access Health Care Physicians, Nursing USA/Faculty: See Exhibit A-Teacher/Learner Expectations. LLC

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Spring Hill, Florida Students must maintain health insurance and provide proof of health insurance to USA. Agency may request copy of proof. Adams Compassionate Healthcare- Undergraduate and ACHN Graduate Nursing Students Chantilly, Virginia Adena Health System MSN, DNP Agency contact: Monica Climer, Coordinator Graduate Clinical [email protected] 740- Chillicothe, Ohio 779-8821 USA/Faculty: Complete Attestation (Exhibit A). Inform facility of curriculum and sequence and of all courses and clinical experiences for each student. Notify facility of proposed schedule of student assignments to facility, including dates, number and names of students, their level of academic preparation.

Student: Complete Exhibit B. Obtain health insurance coverage for the period of the clinical experience.

Florida Hospital (Adventist Health Nursing Agreement covers NURSING Undergraduate Student must be N-95 respirator fit tested prior to System/Sunbelt, Inc.) (to include: • NON APRN attending clinical. Testing can be done for $25 at the Florida Hospital Altamonte - Agency clinic. Nursing Students please see Exhibit C 601 E. Altamonte Drive, Altamonte –Criminal Background Disqualifications Guidelines. Exhibit D- Physical and Mental Requirements. USA Springs, FL must provide a letter of good standing indicating that • Florida Hospital Apopka – a background check and drug screen has been conducted. Provide in writing the names of students. 201 N. Park Avenue, Apopka, FL • Florida Hospital Celebration Agency Contacts: – 400 Celebration Place, Non Clinical Rotation- Debbie Stunkard- Celebration, FL [email protected] • Florida Hospital East Orlando – 7727 Lake Underhill Clinical [email protected] (graduate students please go to www.FHGME.com Road, Orlando, FL for application. • Florida Hospital Kissimmee – Student’s research projects with additional 2450 N. Orange Blossom Trail, requirements: Each student will need to obtain Kissimmee, FL approval from the Principal Investigator on the • Florida Hospital Orlando & research study. The research must be approved in advance by and subject to the review of Hospital's Childrens – 601 E. Rollins Street, Institutional Review Board or receive a determination Orlando, FL of non-human subjects research. If research involves • Florida Hospital Winter the use of animals, the research must be subject to the oversight by an Institutional Animal Care and Garden – 2000 Fowler Grove, Blvd, Use Committee. Student may not serve as Principal Winter Garden, FL Investigators, but may assist as staff personnel, provided they have appropriate supervision. • Winter Park Memorial Students must obtain written approval of both parties Hospital – 200 N. Lakemont before publishing any articles, and will submit all Avenue, Winter Park, FL completed articles, etc., to Hospital for review and approval no less than 60 days prior to the date of Maitland, Florida submission for publication, disclosure or presentation. Florida Hospital (Adventist Health APRN Agreement covers NURSING Student must be N-95 respirator fit tested prior to System/Sunbelt, Inc.) (to include: • attending clinical. Testing can be done for $25 at the

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Florida Hospital Altamonte - Agency clinic. Nursing Students please see Exhibit C –Criminal Background Disqualifications Guidelines. 601 E. Altamonte Drive, Altamonte Exhibit D- Physical and Mental Requirements. USA Springs, FL must provide a letter of good standing indicating that • Florida Hospital Apopka – a background check and drug screen has been conducted. Provide in writing the names of students. 201 N. Park Avenue, Apopka, FL • Florida Hospital Celebration Agency Contacts:

– 400 Celebration Place, Non Clinical Rotation- Debbie Stunkard- Celebration, FL [email protected] • Florida Hospital East Clinical [email protected] Orlando – 7727 Lake Underhill (graduate students please go to www.FHGME.com Road, Orlando, FL for application. • Florida Hospital Kissimmee – Student’s research projects with additional 2450 N. Orange Blossom Trail, requirements: Each student will need to obtain Kissimmee, FL approval from the Principal Investigator on the research study. The research must be approved in • Florida Hospital Orlando & advance by and subject to the review of Hospital's Childrens – 601 E. Rollins Street, Institutional Review Board or receive a determination Orlando, FL of non-human subjects research. If research involves the use of animals, the research must be subject to • Florida Hospital Winter the oversight by an Institutional Animal Care and Garden – 2000 Fowler Grove, Blvd, Use Committee. Student may not serve as Principal Winter Garden, FL Investigators, but may assist as staff personnel, provided they have appropriate supervision. • Winter Park Memorial Students must obtain written approval of both parties Hospital – 200 N. Lakemont before publishing any articles, and will submit all completed articles, etc., to Hospital for review and Avenue, Winter Park, FL approval no less than 60 days prior to the date of Maitland, Florida submission for publication, disclosure or presentation. Adventist Florida Hospital Ocala BSN, MSN, DNP USA/Faculty: Must provide student name, residence address, phone number to agency at least ten days (previously Munroe Regional prior to placement at facility. Prior to commencing Medical Center) performance per the agreement, the COLLEGE shall Ocala, Florida ensure health status of student and faculty entering premises is compliant with the following requirements of the AGENCY and shall produce documentation upon request: Statement by a healthcare provider that student is medically capable of performing internship related duties and is free of any communicable diseases. Documentation of a negative ppd within the last year (two – step ppd if more than one year) or Chest X- Ray if past positive ppd. Documentation of active or passive immunity to Measles, Mumps, Rubella, Rubeola, Diphtheria, Pertussis, Tetanus, Hepatitis B and Varicella.

Student must contact Workforce Development Coordinator with Munroe to complete orientation packet prior to beginning clinicals. Adventist Health System Georgia, RN-BSN, MSN, DNP Students may be required to undergo a health examination. Inc. d/b/a Gordon Hospital Adventist Medical Center Nursing USA/Faculty: Complete a verification form provided by Agency setting forth the name and information for Hanford, California each Student.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Student: Complete Exhibit A. Student must provide copy of background check to Agency, at their own expense. Affiliated Physicians Group MSN and DNP USA/Faculty: At least 15 working days prior to clinicals provide written evidence of requirements set Needham, Massachusetts forth in Appendix A and provide a course description including objectives, a description of the evaluation system. Submit Appendix B for each clinical rotation. Student must be appropriate under the guidelines promulgated by the Massachusetts Executive Office of Health and Human Services (EOHHS). See below for Background check Requirements: Background Checks. The School shall check the Criminal Offender Record Information (“CORI”) for each Participant who may be present on APG’s premises as part of the Program. The School shall disqualify Participants as appropriate under the guidelines promulgated by the Massachusetts Executive Office of Health and Human Service (“EOHHS”) and the Department of Mental Health (“DMH”). These guidelines may be found in the EOHHS Human Resource Policy Manual. No Participant will be permitted to participate in the Program without a satisfactory CORI check. The School shall also notify each Participant that a CORI check will be performed and that the Participant’s participation in the Program is contingent on the outcome of the CORI check. The School shall comply with all requirements relating to dissemination of information related to the CORI check. CORI checks and disqualification decisions must be made at least 10 business days prior to the date on which the Participant is scheduled to begin. The School may comply with these CORI obligations independently, or it may request that APG conduct CORI checks and disqualify Participants as appropriate on the School’s behalf, at a cost to the School. If the School opts to perform the CORI checks and make determinations regarding disqualification independently, the School will represent and warrant that it has performed a CORI check for each Participant and disqualified ineligible Participants consistent with EOHHS and DMH guidelines, and will provide documentation of these facts upon request. If the School delegates its CORI obligations to APG, APG will initiate checks only after it has received a release from the School for each Participant and all decisions by APG shall be final.

Affinity Health Group, LLC Undergraduate and Graduate Students Monroe, Louisiana AHS Hillcrest Healthcare System, MSN, DNP See Exhibit A for covered facilities. See Exhibit C for Background Requirements. LLC (Includes the following sites: Student must complete and sign Exhibit D. Bailey Medical Center, Hillcrest Hospital Claremore, Hillcrest Hospital Cushing, Hillcrest Hospital Henryetta, Hillcrest Medical Center, Oklahoma Physicians Group- Utica

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Park Clinic), Hillcrest Hospital South) Tulsa, Oklahoma Aiken Regional Medical Centers Nursing USA/Faculty: Prior to the beginning of experience provide number of students, possible dates of Aiken, South Carolina experience, names of students, objectives of program.

Students: Must sign a confidentiality agreement provided by the Facility. Provide evidence to the Facility of having received any immunizations and testing that may be required by Facility. Must obtain and maintain health insurance while in a clinical experience at Facility. Akron General Medical Center Graduate GRADUATE STUDENTS. USA must notify agency one month prior to Akron, Ohio beginning of clinicals for each student. USA Faculty must provide orientation session to preceptor to include: goals, objectives of program, faculty’s contact information, and overview of expectations. Students must have current RN license in the state of practice. Student must participate in orientation procedures as required by agency. Alabama Board of Nursing Graduate Nursing USA/Faculty: Shall ensure that its faculty and Programs Students do not participate in any clinical learning Montgomery, Alabama experience which may pose a conflict of interest. A conflict of interest exists if the Student or faculty member is working on or will have access to data regarding a matter that pertains to him/herself or an employer, family member, educational institution, or friend of the Student or faculty member, as well as any other relationship or factual scenario which could reasonably be construed to compromise the integrity of the ABN’s regulation of nurses and nursing education programs. Provide the ABN with a schedule and learning objectives for the student prior to the beginning of the clinical learning experience. USA understands and agrees that its Students and faculty shall not be permitted to access any data of the ABN prior to executing a Confidentiality Agreement and, if necessary, a Data Use Agreement or other agreements required by the ABN. The Educational Institution agrees that any Student or faculty member who violates a Confidentiality Agreement, Data Use Agreement, or other agreement required by the ABN will be removed from the ABN clinical site and may face other consequences as described in said Agreements. Alabama Department of Public Nursing Contact: Angela Dubose- [email protected]. Health, (Alabama inclusive) Alabama Regional Medical Services Undergraduate and Birmingham, Alabama Graduate Nursing Students Alabama Providence Healthcare Undergraduate and Covers Providence Hospital and Clinics. See Graduate Nursing Directory for complete listing. Services (providence hospital medical group) Mobile, Alabama

Alameda Health System Undergraduate and USA/Faculty: Submit all clinical rotation requests Graduate Nursing through the Centralized Clinical Placement System. Oakland, California

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered See Exhibit F for the Primary Source Verification. These must be met at least 14 days prior to clinical experience. Must make an appointment with the site at least 14 days prior to clinical experience-see Exhibit F. Student must complete orientation at facility. Alaska Tribal Health Nursing Agency Education Contact: Zachary Owen [email protected]. Consortium/Alaska Native Medical USA/Faculty: Provide to Facility a listing of students Center who will be participating in clinicals. Also provide to Anchorage, Alaska Facility any change in student’s status. Provide opportunity to receive Hepatitis B vaccine to clinical Renewal in process-set to expire students. on 9/30/2018 Student: Must provide drug test results to Facility's Human Resources Department during the onboarding process. Must maintain personal medical insurance coverage while at Facility. Must have training in universal precautions and transmission of blood-borne pathogens.

Alegent Health NP Omaha, Nebraska Allegan Healthcare Group MSN and DNP Allegan, Michigan Allegheny Health Network MSN and DNP See Exhibit A-Required Health Screening Clearance. Submit to Agency prior to clinical experience, Pittsburgh, Pennsylvania number of students, dates and hours that they will be assigned to Agency. The expected level experience that they will be assigned, expected objectives and health requirements listed on Exhibit A. Alliance Health Center Nursing Programs USA/Faculty: Provide the names and information relevant to training within a reasonable time prior to Meridian, Mississippi clinicals. Agency contact is: Leigh Ann Posey- [email protected] Student: Must obtain criminal background check and child abuse clearance check prior to clinicals. Must sign a patient confidentiality agreement, which Agency will provide. AllianceHealth Durant (previously RN-BSN, MSN, DNP USA/Faculty: See Addendum 1 & 2 for Patient Care Medical Center of Southeastern Oklahoma) Duties Student: Completed addenda 4 & 5. Must have Durant, OK health insurance during their clinical rotation at Facility. AllianceHealth Woodward Nurse Practitioner Student: Complete Addenda 4, 5 and 6. For each Instructor and Student who will participate in the Woodward, Oklahoma clinical rotations the School shall provide to the Facility verification of the following immunizations and tests:

1. A complete Hepatitis B vaccination series (series of three or waiver) 2. Negative PPD or chest X-ray 3. MMR vaccinations(s) or positive titers 4. A written verification of varicella history, varicella vaccinations or a varicella titer by a physician or a physician’s designee 5. A background check that includes OIG.

The School shall require that each Student and Instructor before beginning the clinical rotation have current CPR certification that meets standards acceptable to the Facility.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Alpine Medical Associates Undergraduate and Graduate Nursing Jersey City, New Jersey Students AltaPointe Health Systems, Inc. (sites BSN, RN-BSN, MSN, Please note the contact person for clinicals are as covered: Bayview Professional Assoc., DNP follows:

Altapointe Children’s Outpatient, AltaPointe AltaPointe Health Systems, Inc. (Baldwin County Adult Outpatient, EastPointe Hospital, Mental Health site) BayPointe Hospital, Zeigler Outpatient ARS, Renee Presley- [email protected] or (251) Community Counseling Center of South 378-6528 or (251) 378-6528 Mobile County, Community Counseling Center of Washington County, Community AltaPointe Health Systems, Inc. (Mobile site) Counseling Center of Fairhope, AHS Kelly Hughes - [email protected] or (251) 473- Community Counseling Center of Foley, 4423 Community Counseling Center of Bay Minette) Mobile, Alabama

American Family Care, Inc. BSN, RN-BSN, MSN, DNP Birmingham, Alabama American Health Network of Ohio, USA/Faculty: Verify annual negative Tuberculin skin test or if positive, a negative chest X-ray; Hepatitis B PC immunization status; and physical exam prior to Indianapolis, Indiana clinicals. Amory HMA Physicians Graduate Nursing USA/Faculty: See Addenda 1&2 Student Duties. Nurse Practitioner Management, LLC (covers; Amory Student: Must complete Addenda 4-6. Must contact Pediatric Clinic, Primary Medicine Brenda Langford in HR to set up a time to attend Clinic, Family Medicine Clinic) orientation. Her number is 662-256-6286. a negative TB skin test within the past year or, in the Amory, Mississippi event of a positive TB skin test, a chest x-ray within the past three (3) years; OR provide evidence of no TB disease per negative result of interferon-gamma As of 5/3/2017 now owned by Curae release assay blood test (T-Spot or Quantiferon Health, Inc. Gold) within twelve (12) months of student activity at facility; (b) a completed series of Hepatitis-B vaccine, having begun the series, or informed refusal of the vaccine; and (c) any other appropriate immunizations requested by Facility.

Ensure that Students are aware of the Substance Policy. See Addendum 4.

Provide the Facility with a copy of each Student’s completed (1) Substance Policy Consent Form (See Addendum 4) and (2) Background Consent Form (See Addendum 5).

Criminal Records Check Students’ criminal records shall be checked at the federal, state, and local levels before referring Students to Facility and thereafter as often as is required by law. The Facility CEO will have the authority to make the final decision regarding the referral of any Student with a criminal record. Students must execute a Student Background Consent Form (See Addendum 5). Andalusia Regional Hospital Andalusia, Alabama

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Anderson Regional Medical Center BSN, RN-BSN, MSN, DNP and Anderson Regional Medical Center-South Campus South Campus covers the Children’s Clinic, Airpark Family Medical Clinic, Anderson Cardiac Surgical Assoc, Anderson Ear, Nose, and Throat, Anderson East MS Endoscopic, The Purvis Clinic, Anderson Urology Clinic of Meridian, Anderson Neurology Center, Anderson Family Medical Center-Enterprise Meridian, Mississippi Angel Medical Center, Inc. (Mission Following programs Questions for onboarding and orientation processes: only; Mission Education Services facility) MSN FNP 828-213-0779 Franklin, North Carolina MSN Dual Role [email protected] MSN Adult Geron CNS USA/Faculty: Submit roster of students who will participate in the clinical experience at Facility. Students-May be required to participate in any required orientation process developed by the Facility. AnMed Health Anderson, South Carolina Anniston Pediatrics, Inc. Undergraduate and Graduate Students Anniston, Alabama

Apogee Medical Management, Advanced Practice Students: Must maintain health insurance during Nursing clinicals. Must have education in OSHA/Blood Borne Inc.(covers all of the US) Pathogens and HIPAA regulations prior to clinicals. Phoenix, Arizona Appalachian Regional Healthcare USA/Faculty: Will send information to Boone, North Carolina the facility prior to initiation of clinicals to include dates of assignment, number of students, name and pertinent information about students, objectives for clinical, curriculum outline and types of previous healthcare/clinical experience. Provide facility with an exposure control plan and guidelines for its students in accordance with OSHA Standards for Bloodborne Pathogens and TB or other applicable guidelines upon request. Student: Must obtain adequate health insurance.

Appalachian Regional Healthcare, USA/Faculty: Must complete Exhibit A, return to contract office for signature, then return to Education Inc. Coordinator at ARH facility. Contact the Education Hazard, Kentucky Coordinator at the ARH facility student will be seeking placement.

Student: Obtain health insurance coverage.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Archbold Memorial Hospital (also Undergraduate and Students must have annual PPD. Graduate Nursing covered: Brooks County Hospital, Grady General Hospital, Mitchell County Hospital, Mitchell Convalescent Center, Glenn Mor Nursing Home, Archbold Health Services and Archbold Medical Group) Thomasville, Georgia Arizona Community Physicians, LLC Undergraduate and Students must complete Appendix A. Graduate Nursing Tucson, Arizona Arkansas Children’s Hospital Nursing Faculty must provide facility official with students’ names, dates, and hours of assignment and level of Little Rock, Arkansas care by students.

Contact: Tracey L. Stone Academic Nursing Education [email protected]

Arkansas Department of Health & Women’s Health, USA/Faculty: Adult, Community Agrees to provide the Regional Patient Care Human Services (Arkansas Health Nursing, BSN, Manager a list of the following for all students and inclusive) MSN, APRN, DNP. faculty who will be on-site at the Department of Health: A list of names of the students and faculty; Proof of tuberculosis testing or screening Proof of MMR, Hepatitis B, Tetanus, Varicella, and Influenza vaccinations

Any student or faculty who will be on site at the Department of Health who is not up to date on the vaccinations listed must receive the required vaccinations prior to reporting to their assigned site(s).

Any students or faculty who does not wish to be vaccinated must provide the Patient Care Manager with proof of vaccination exemption prior to reporting to their assigned site(s). The Department of Health Immunization Medical Director reserves the right to accept or deny any exemptions for the purpose of student /faculty participation in Department of Health on-site clinical activities. Any Student or faculty whose exemption is accepted, are subject to the Department of Health’s policies related to direct patient care, and may be required to wear a mask or be excluded from participating in certain activities during an outbreak situation, up to and including exclusion from the Department of Health premises. Evidence of a license in good standing in nursing, medical, pharmacy, or allied health for each faculty member, if that faculty member will be on-site during the clinical rotation. . Provide the Department of Health site a list of learning objectives for the student and timeframe in which objectives are to be completed.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Research proposals that involve ADH clients and/or client records shall be conducted in compliance with all applicable laws and rules dealing with confidentiality and consent. The research proposal must be approved by the ADH Science Advisory Committee. The Research Proposal must be sent to Center for Local Public Health, along with documentation of Institutional Review Board (IRB) findings related to the status of research on human participants. Students and faculty shall wear a properly displayed student/faculty ID badge; and will dress behave professionally at all times and in accordance with any established Department of Health dress code or policy. In accordance with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Standards (U.S.C. 1320d et seq. ) and its implementing regulations including but not limited to 45 Codes of Federal Regulations (CFR) parts 142, 160, 162, and 164, and hereinafter referred to the as the Privacy Rule, all students and faculty who will be on-site or have access to Protected Health Information (PHI) agree to maintain and not disclose any PHI and undergo the Department of Health’s HIPAA training prior to the first day of clinical activity in the local health unit or before doing any research. The student/faculty must further comply with any other applicable federal law and regulations. Students will complete the Department of Health online HIPAA training module prior to the first day of their clinical experience.

Arkansas Health Group Nursing Programs At least thirty (30) days before the start of a particular class/rotation, the Program must provide to Little Rock, Arkansas Practice Plus Human Resources Administration with the Educational Participant name(s) and required identifying information, Faculty/preceptor name(s), class/rotation dates and sites, certification of background checks and immunization/medical clearances, and a HIPAA Medical Records Access and Confidentiality Agreement signed by each Educational Participant and Faculty/preceptor. Practice-Plus’s Human Resources Administration must approve the Educational Participant participating at a Practice-Plus Clinic in a program covered by an affiliation agreement prior to the Educational Participant being given access to Practice-Plus Clinic facilities, patients or patient records. Armstrong County Memorial Graduate Nursing USA/Faculty: Submit copy of the student Hospital programs and learning objectives and curriculum prior to Nurse Practitioner clinicals. See Exhibit B for Medical Information Kittanning, Pennsylvania Checklist. Return a completed copy of Exhibit B to the clinical site when requested. Students: Must obtain and maintain health insurance coverage for the duration of their clinical experience. Asante’ (to include: Asante Rogue Nursing USA/Faculty: Request placement at least 90 days Regional Medical Center, Medford, Oregon, prior to clinical experience and provide the schedule Asante Three Rivers Medical Center, Grants of experience for approval. See NON-EMPLOYEE Pass, Oregon, and Asante Ashland Community CHECKLIST for requirements.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Hospital, Ashland, Oregon, and Asante Physician Partners) Student: May be required to complete online Medford, Oregon Bloodborne pathogens and HIPAA modules from facility. Ashley County Medical Center Undergraduate and Graduate Nursing Crossett, Arkansas Aspirus, Inc. Student must retain Caregiver’s Background Check under Wisconsin law through the Department of Wausau, Wisconsin Health Services. The results must be given to USA for their records.

Atlantic General Hospital Graduate Nursing USA/Faculty: Provide agency with clinical learning Programs experience program and objectives and approve the Corporation schedules. Roster with names of students and Berlin, Maryland rotation schedule. Contact: Ingrid Cathell, Medical Staff Coordinator, [email protected].

Students: Must have criminal background check covering the prior seven years performed within (12) twelve months prior to the start of clinical experience.

AU Medical Center formerly Nursing USA/Faculty: Provide to Facility the number of students, course of instruction, and dates of clinical Georgia Regents Medical Center at least 14 days prior to clinical. Student must supply Augusta, Georgia Facility a written certification and attestation verifying the student’s successful completion of HIPAA training. Student must sign written agreement obligating them to observe all rules and policies established by Facility and maintain the confidentiality of patient info and refrain from publishing any material related to the agreement that identifies or uses the name of the Board of Regents, or the Facility.

Augusta Health Graduate Nursing USA/Faculty: Provide to facility not less than one Programs month prior to clinical experience the name of each Fishersville, Virginia student and a proposed schedule of assignment; the expected level of experience to which school proposes each student will be assigned; the expected learning objectives of each student; a summary of each student’s education and clinical experience and field work. Student: Must execute an agreement acknowledging their obligations to PHI, provided by facility. Augustine Health Group, LLC Graduate Faculty should contact Tajuane Dockery 803-865- 4793 [email protected] to Columbia, South Carolina schedule students participating in clinicals.

Students complete Exhibit B. Aurora Medical Group, Inc. BSN, RN-BSN, MSN, To include all Aurora Health Care, Inc. facilities. DNP Faculty, please see Exhibit A-program Milwaukee, Wisconsin memorandum.

USA Faculty please, see the online form on the following website. https://medicalprofessionals.aurorahealthcar e.org/nurses/student-system/clinics- ambulatory-care/art/advanced-practice-rn- policy.pdf

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered

Please read the requirements document for this facility.

Avera Health (to include Avera USA/Faculty: Upon request submit to agency the dates, time, number and academic level of McKennan, Avera St. Luke’s, Avera students to be assigned to each unit within Queen of Peace, Avera Sacred Heart agency. Name, license number and credentials of Hospita, Avera St. Mary’s, Avera faculty member providing the practicum Marshall, Avera St. Benedict Health instruction. Prior notice of any proposed changes to any assigned student's schedule. Center, Aveara St. Anthony’s, Avera Complete the Faculty Verification of Student Holy Family, Avera@Home, and Avera Orientation form. Health Plans, Inc.) Student: See Agency immunization guidelines. Sioux Falls, South Dakota (main ofc.) Complete HIPPA training prior to clinicals. Avera Hospital will be using mCE to track Undergraduate Nursing students. If you send students in other Programs of study, please contact Avera Hospital directly to discuss how to set up rotations/onboard students since it will NOT be done via mCE. Avera Hospital is not using mCE for Instructor Tracking. Special Notes for Avera Hospital Avera Hospital does not require the Compliance Checklist to be filled out. Instead, Clinical Coordinators can attest to their student’s compliance, letting the Hospital know that if they ask for the documentation they can provide that if asked.

Azalea Health (Rural Health Care, BSN, RN-BSN, MSN, DNP Inc.) Palatka, Florida Renewal in process-set to expire 10/9/2018

Agency Name Programs Agency Requirements Covered Baker County Health Department BSN, RN-BSN, MSN, DNP Macclenny, Florida Baldwin County Public Schools BSN, RN-BSN, Faculty must notify school prior to clinical MSN, DNP Fairhope, Alabama experience Banner Health Advanced Practice USA Faculty Prior to the utilization of Phoenix, Arizona *Now Banner this agreement, please contact USA Health agreement also covers: Clinical Affairs regarding MyClinical University Medical Center Corp. and Exchange onboarding process. University Physicians

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Tucson, Arizona* Faculty and Students please see the facility’s Policies and Procedures for the Influenza Vaccination of Healthcare Personnel. Please see ALL exhibits.

Students must complete the Influenza Attachments.

Students are responsible for their own health insurance. Students are required to complete a BH Orientation which may include on-line lessons. Faculty and Students please refer to Exhibit A- Health Standards (available from the contract office) Students must comply with OSHA guidelines and training. If student’s program requirements include access and experience with patients in isolated rooms, due to airborne infectious disease, student must have obtained a respiratory mask-fit testing as required by OSHA. Students may be asked to submit to a “for cause” drug screening by BH. Students must agree in writing that BH may at any time require a “for cause” drug screen, execute consent for release of results of such screen information to BH. Student may be precluded from participating in a Rotation at BH if “for cause” drug screen is declined or student does not execute consent of release. BH shall conduct a background investigation on (on- site) Faculty and students participating in the Program at BH. USA shall provide BH with any information necessary to conduct such background checks. Students are not permitted access to the physician parking area or physician lounge. Faculty shall provide BH a current copy of the applicable Program syllabus for all students in each Rotation, as well as the approved Statement of Objectives for the clinical experience desired of its students. Faculty shall supply student names no less than fourteen (14) days prior to Rotation. Faculty must notify BH of any student placed on the Sanctions list by the Department of Health and Human Services.

Baptist Health Care Corporation Nurse Practitioner Students please request Exhibit A and B Students ONLY Pensacola, Florida prior to starting clinicals and bring with Includes: Baptist Hospital, Pensacola, FL, you to the Baptist Health Care Gulf Breeze Hospital, Gulf Breeze, FL Orientation. Must be completed before Baptist Medical Group, Pace, FL clinicals.

Attestation Form must be completed and signed by USA Faculty and emailed to Tyler Bucznski - [email protected] Baptist Health Floyd Nursing Students must complete Exhibit A. New Albany, Indiana

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Baptist Health Madisonville, Inc. USA/Faculty: Provide any requested student information (licensure, immunization record, TB skin Madisonville, Kentucky test, background check results) to Facility. Student: Complete the Statement of Understanding and Confidentiality Agreement. Baptist Health Medical Center-Little Nurse Practitioner Students must have background checks Rock with a Physician including Arkansas Statewide and Nationwide Preceptor Federal Criminal Record searches; Arkansas Little Rock, Arkansas Crime Information Center Sex Offender Registry, OIG List of Excluded Individuals and Entities (LEIE), Government Services Administration System for Award Management (SAM), list of parties excluded from federal programs, Arkansas Department of Human Services (Medicaid) exclusion list, List of Suspended or Debarred Vendors from DFA, OFAC Specially Designated Nationals List (Terrorist List), and Certified 9-Panel Drug Test, immunization/medical clearances (including TB, Rubella, Rubeola, Mumps, Varicella, Hepatitis B, or waiver, and Flu); At least thirty (30) days before the start of a particular class/rotation, USA must provide Hospital Administration with the Student’s name(s) and required identifying information Baptist Health - Little Rock and North Nursing At least thirty (30) days before the start of a particular class/rotation, the Program must provide Little Rock Hospital Administration with the Educational Little Rock, Arkansas Participant name(s) and required identifying information, Faculty/preceptor name(s), class/rotation dates and sites, certification of background checks and immunization/medical clearances, and a HIPAA Medical Records Access and Confidentiality Agreement signed by each Educational Participant and Faculty/preceptor. Baptist Health System (covers- BSN, RN-BSN, Agency Education Contact: Kimberly Davis- Princeton, Shelby, Walker and Citizen’s) MSN, DNP [email protected].

Birmingham, Alabama USA/Faculty: Provide written statement of objectives for each clinical rotation as requested. Students: Must complete orientation program as designated by Agency prior to clinical experience. Must avoid contact with respiratory isolation unless fit tested with the N95 3M mask. Must have training in HIPAA requirements and OSHA regulations. Baptist Health San Antonio Nursing Programs USA/Faculty: Complete Exhibit C-Attestation. See orientation packet. San Antonio, Texas Students; Complete Exhibits A&B. Completion of a two-step tuberculin skin test (within the last six months) or evidence that each Program Participant is free of symptoms of pulmonary disease if the skin test is positive, a chest x-ray following a positive TB test result, negative drug screening, physical examination, proof of rubella, and rubeola immunity by positive antibody titers or 2 doses of MMR, and evidence of completion of the series of three hepatitis B vaccinations (if required by applicable law or Hospital policy). Bay Medical Center –Sacred Heart Nursing USA/Faculty: Complete Exhibit C-Attestation Health System Students: Complete Exhibits A & B.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Panama City, Florida Baylor All Saints Medical Center MSN and DNP USA/Faculty: At least 90 days prior to the Fort Worth, Texas beginning of each clinical experience, USA must furnish to Facility USA’s clinical requirements along with the information included in Exhibit A. 3.1 At least ten (10) days prior to the commencement of each period of clinical educational experience, School shall furnish to Facility for each Student participating in the clinical educational program (a) the name and health status report of the Student; (b) a letter of verification stating that the results of a criminal background check and comprehensive drug screen on the Student show no negative, derogatory, or adverse information; and (c) such other data as Facility may request. Student: Must complete Exhibit B- Confidentiality Agreement. Baptist Health System-Florida BSN, RN-BSN, Must contact Clinical Affairs for MyClinical Exchange MSN, DNP request. If this is not completed your rotation will not Jacksonville, Florida count. (to include: Baptist Medical Center, Baptist Medical Center Beaches, Baptist Medical Center Nassau, Baptist Medical Center South, Baptist Medical USA Faculty and Students please see Exhibit A for Center-Outpatient Center, Wolfson Children’s facilities covered by agreement. Hospital, Baptist Emergency Center Clay, Baptist Contact: Kristy Johnson 904-202-8390. Primary Care, Inc., Baptist Cardiology, Baptist ENT USA/Faculty: Provide student names, days and Specialists, Baptist Neurology, Baptist Pulmonary, hours they will be assigned and services which their Baptist Urology, Baptist Southeast Gynecologic assignment is desired in a timely manner. Provide Oncology Associates, Jacksonville Orthopaedic statement of health status for each student, to Institute, Lyerly Baptist, Baptist Health Rehab include proof of immunity to Rubella, Rubeola and Centers) chicken pox or provide documentation of appropriate vaccinations, and completed OSHA form documenting negative TB skin test within 90 days of participation in the Program. Facility may require liability insurance indicate students name, if requested please contact the USA Clinical Affairs Department.

Student: Complete Exhibit B-Participation Agreement. Baptist Health System Agency requesting to update agreement-in process.

San Antonio, Texas *Student must complete Exhibit A & B before starting clinicals. (See Faculty for information) *Students are required to have flu and HINI vaccines by December 15, 2009 and the Proof of Vaccination form must be completed prior to clinicals. (See faculty member regarding form). Baptist Healthcare System, Inc., Student must sign Statement of Understanding and Confidentiality Agreement. d/b/a Baptist Health Lexington Lexington, Kentucky Baptist Health Medical Group Nurse Practitioner See and complete Exhibits A&B.

Louisville, Kentucky Baptist Health System, Inc. d/b/a MSN, DNP USA Faculty must provide student info to hospital at least 30days prior to beginning clinical .Faculty who Baptist Health Paducah make on-site visits must be licensed in Kentucky Paducah, Kentucky with current TB skin tests and immunizations.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Students must complete and sign Exhibit B. Obtain supervising physician’s (preceptor) signature on Exhibit A.

Baptist Hospital of Miami (to include: Undergraduate and Graduate Students Please ensure all students and faculty are in Doctors Hospital, Inc., Homestead compliance should they be entering BHSF. Any Hospital, Inc., South Miami Hospital, Inc., current BHSF employee who desires to perform Mariners Hospital, Inc., West Kendall activities at a BHSF facility as a student may do Baptist Hospital, Inc., and Baptist such, provided that the employee does not regularly work at the BHSF facility(s) where the employee will Outpatient Services, Inc., Baptist be performing activities as a student. For example, Children’s) an employee works at Baptist Hospital of Miami. The employee is enrolled in a program that requires students to complete clinical hours at a hospital. After the employee obtains approval from the Baptist Student Affiliations Office, the employee may perform the practicum training in his/her capacity as a student at any BHSF facility other than Baptist Hospital of Miami.

Faculty must complete Schedule A. Student must complete the Student Agreement and Acknowledgement form. Faculty must have active Florida license and CPR Certification. Please ask for Section 9 School Certification forms. Once students and faculty are cleared for clinical rotation within BHSF they are instructed to obtain the identification badges for the rotation. The instruction is provided in the clinical clearance email sent by the student affiliations office at agency. Please ensure the students and faculty report to the respective entity’s security office Monday – Friday, during the hours of 9:00a - 5:00p, in order to obtain the badges. If the clinical hours are on either Saturday or Sunday, please ensure the badges are obtained prior to the first day of clinical rotation.

Baptist Medical Group MSN, DNP FACULTY MUST CONTACT CLINICAL MS, TN, and AR AFFAIRS BEFORE APPLYING TO THIS FACILITY FOR CLINICAL PLACEMENT. NOTE: APRN, MD/DO preceptors ONBOARDING PROCESS CAN TAKE only for the TN Baptist Medical AT LEAST 4 MONTHS. MOU FOR EACH CLINICAL Group EXPERIENCE IS REQUIRED Faculty (Only) please contact Beth Collier. The MOU will be in lieu of an LON.

The EPIC student note training

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered In order to register students for training, we will need the following: a. Full Name b. DOB c. Last 4 digits of the Social Security number d. Highest degree currently held e. Class selection ( 8:30 or 1:30)

Please forward the above information to Cassandra Gray, Executive Administrative Secretary, at BMG. This training will be offered each month. USA/Faculty: Upon request, provide written copies of the general curriculum and clinical experience objectives to a Baptist designee. Complete Exhibit A with USA's preceptor guidelines. Student: Must fully complete and return Attachment One-Preceptor Agreement. Will be required to sign an affidavit regarding the student's prior criminal history as required.

Baptist Medical Center South BSN, RN-BSN, See attachment A-Competency Validation Policy MSN, DNP Clinical Instructors and Students. (includes Baptist Medical Center East Students must complete required training before and Prattville Baptist Hospital) beginning training. Student may be required to sign Montgomery, Alabama an individual agreement with agency. Baptist Memorial Hospital – Golden BSN, RN-BSN, FACULTY MUST CONTACT CLINICAL MSN, PM Cert, DNP Triangle AFFAIRS BEFORE APPLYING TO THIS Columbus, Mississippi FACILITY FOR CLINICAL PLACEMENT. ONBOARDING PROCESS CAN TAKE AT LEAST 4 MONTHS. MOU will need to be completed. Students please complete the application and submit at https://www.baptistonline.org/gradnurs e-application

Baptist Memorial Hospital-Memphis MSN and DNP FACULTY MUST CONTACT CLINICAL Memphis, Tennessee AFFAIRS BEFORE APPLYING TO THIS FACILITY FOR CLINICAL PLACEMENT. ONBOARDING PROCESS CAN TAKE AT LEAST 4 MONTHS. MOU FOR EACH CLINICAL EXPERIENCE IS REQUIRED Faculty (Only) please contact Beth Collier. The MOU will be in lieu of an LON. .Provide written copies of the general curriculum and clinical experience objectives to a Baptist designee if so requested. Designate for participation only such students and faculty as have passed and/or present evidence of the following: A satisfactory physical examination, including a negative nine panel drug screen. PPD Skin Test. TB SKIN TEST #1 within thirty (30) days prior to start date. If history of past reactive TB skin test, a chest x-ray is required within six (6)

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered months prior to start date. Varicella (Chicken Pox) Documentation of two (2) varicella vaccinations, Documented Positive Titer, Rubeola (Red Measles), Documented receipt of two (2) doses of live measles (or MMR) vaccination after first birthday, or Documented Positive Titer, Mumps, Documented receipt of two (2) doses of live mumps (or MMR) vaccination after first birthday, or, Documented Positive Titer, Rubella (German Measles) Documented receipt of one (1) dose of live rubella vaccination (or MMR) after first birthday, or Documented Positive Titer, Influenza, Proof of current vaccination required October 1st through March 31st, Hepatitis B Vaccination, Documentation of three (3) vaccinations, or Declination form. Students please complete the application and submit at https://www.baptistonline.org/gradnurse- application

Baptist Memorial Hospital-North BSN, MSN, Mississippi FACULTY MUST CONTACT CLINICAL Post Master’s AFFAIRS BEFORE APPLYING TO THIS Oxford, Mississippi Certificate DNP FACILITY FOR CLINICAL PLACEMENT. ONBOARDING PROCESS CAN TAKE AT LEAST 4 MONTHS. MOU will need to be completed. Request online application from Clinical Affairs (Beth).

USA/Faculty: Provide written copies of the general curriculum and clinical experience objectives to a Baptist designee if so requested. Student: A satisfactory physical examination, including a negative nine (9) panel drug screen. PPD Skin Test ,TB SKIN TEST #1 within thirty (30) days prior to start date. If history of past reactive TB skin test, a chest x-ray is required within six (6) months prior to start date Varicella (Chicken Pox) Documentation of two (2) varicella vaccinations Documented Positive Titer Rubeola (Red Measles) Documented receipt of two (2) doses of live measles (or MMR) vaccination after first birthday, or Documented Positive Titer Mumps, Documented receipt of two (2) doses of live mumps (or MMR) vaccination after first birthday, or Documented Positive Titer Rubella (German Measles) Documented receipt of one (1) dose of live rubella vaccination (or MMR) after first birthday, or Documented Positive Titer Influenza, Proof of current vaccination required October 1st through March 31st Hepatitis B Vaccination, Documentation of three (3) vaccinations, or Declination form.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered

School shall notify students of the requirement of a criminal background check at the earliest possible opportunity, preferably prior to enrollment in the program. School will inform the student concerning the eligibility standards that would exclude his/her participation in the clinical placement and thus prevent the student from successfully completing School’s program. School will inform the student that it is his/her responsibility to pay for the background check and to have it completed prior to clinical placement. School will additionally inform the student that the background check must be completed no earlier than one year prior to the student's initial clinical placement.

ONLY IN THE EVENT SCHOOL IS LOCATED OUTSIDE MISSISSIPPI AND SCHOOL’S STUDENT WILL BE PLACED AT A BAPTIST FACILITY IN MISSISSIPPI, School acknowledges that said student will be required to sign an affidavit regarding the student’s prior criminal history as required by M.C.A. §43-11-13, et seq. School further acknowledges and shall inform its student that should the student refuse to execute such an affidavit, then such student will not be placed at a Baptist facility located in Mississippi.

Students please complete the application and submit at https://www.baptistonline.org/gradnurse-application

Baptist Memorial Hospital-Union City RN-BSN, MSN, PM FACULTY MUST CONTACT CLINICAL Cert, DNP Union City, Tennessee AFFAIRS BEFORE APPLYING TO THIS FACILITY FOR CLINICAL PLACEMENT. ONBOARDING PROCESS CAN TAKE AT LEAST 4 MONTHS. Request online application from Clinical Affairs (Beth).

USA/Faculty: Provide written copies of the general curriculum and clinical experience objectives to a Baptist designee if requested. Students: Must have satisfactory physical examination, annual TB test, Hepatitis B vaccine series or signed waiver; students born on or after 1957 must have two MMR vaccines given after one year of age or serologic evidence of immunity to Rubella and Rubeola; Must have annual influenza vaccine. Must have background check no earlier than one year prior to the clinical placement. Students please complete the application and submit at https://www.baptistonline.org/gradnurse- application

Barnes-Jewish Hospital NP, DNP St. Louis, Missouri NP and DNP Students

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered ***Please see agency specific LON under the agency attachments in Sakai*** USA/Faculty: Provide facility with names, health status reports, immunizations required by facility prior to beginning of clinicals. Verify that student has completed and passed the requirements noted in the BJC guidelines (Exhibit 2). Meet with facility personnel prior to and following clinicals. Must provide proof of student's general liability insurance. Students: Must sign Statement of Confidentiality (Exhibit 1). Must obtain and maintain health insurance.

Barnes-Jewish Hospital CNS CNS Students St. Louis, Missouri ***Please see agency specific LON under the agency attachments in Sakai*** USA/Faculty: Provide facility with names, health status reports, immunizations required by facility prior to beginning of clinicals. Verify that student has completed and passed the requirements noted in the BJC guidelines (Exhibit 2). Meet with facility personnel prior to and following clinicals. Must provide proof of student's general liability insurance. Students: Must sign Statement of Confidentiality (Exhibit 1). Must obtain and maintain health insurance. Must obtain and maintain general liability insurance with amounts of $1 million per occurrence, $3 million annual aggregate, on an occurrence basis.

Baton Rouge General Medical BSN, RN-BSN, Physician Assistant, Physical Therapy, Occupational MSN, DNP Therapy and Nursing Students contract. All students Center (and its affiliates) must be approved for the rotation through the Baton Rouge, Louisiana Education Dept. at BRGMC. Faculty, please see the agency attachments that must be completed. Faculty and Students please see the BRGMC Affiliate List. Baxter Regional Medical Center BSN, RN-BSN, USA Faculty please see Exhibit D: ONBOARDING MSN, DNP Nursing Clinical Programs at Facility. Mountain Home, Arkansas USA/Faculty: Must provide Instructor name and contact information to Aleta Newberry [email protected]..

Student: Must provide evidence they have met all applicable requirements of current AHA CPR certification, TB Mantoux test, MMR immunity, and compliance with OSHA requirements for prevention of transmission of blood borne pathogens and TB. Must obtain and maintain comprehensive healthcare insurance during clinicals. Must attend Facility's orientation to include HIPAA training, Infection Control, Safety Requirements, and No Smoking Policy.

BayCare Health System, Inc. (to BSN, RN-BSN, APRN students must complete the “Physician include: Morton Plant Hospital Association, Inc. MSN, DNP Sponsored Student Application” d/b/a Morton Plant Hospital and Morton Plant North Bay Hospital; Trustees of Mease Hospital, Inc. Faculty and Students please see Attachment B d/b/a Mease Countryside Hospital and Mease (Employee Health Requirements for Students and Dunedin Hospital; St. Anthony’s Hospital, Inc.; St.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Joseph’s Hospital, Inc. d/b/a St. Joseph’s Faculty & Attachment C (Team Resources Children’s Hospital, St. Joseph’s Women’s Contractor Requirements for Students and Faculty). Hospital, and St. Joseph’s Hospital - North; South Florida Baptist Hospital, Inc.; BayCare Alliant Hospital, Inc.; BayCare Behavioral Health Inc. d/b/a The Harbor Behavioral Health Care Institute, Inc.; Behavioral Health Management Services, Inc. d/b/a BayCare Life Management, Inc.; BayCare Home Care, Inc.; SC Physicians, LLC; St. Anthony’s Specialists, LLC; St. Anthony’s Primary Care, LLC; Morton Plant Mease Primary Care, Inc.; HealthPoint Medical Group, Inc.; , BayCare Medical Group, and Winter Haven Hospital, Inc.) Clearwater, Florida Renewal in process-set to expire 10/3/2018 Bayfront Health Saint Petersburg Nurse Practitioner USA/Faculty: Educate students about clinical safety and Nursing and OSHA blood borne pathogens standards and St. Petersburg, Florida Informatics tuberculosis transmission prevention prior to clinicals. Student: Please see Addendum 1-5. Must have a negative TB skin test within the past year or if a positive TB skin test a chest x-ray within the past 3 years. Completed series of Hepatitis-B vaccine, or informed refusal of the vaccine. Must obtain health insurance coverage. Baylor University Medical Center Graduate Nursing USA/Faculty: Complete and submit Attestation to Students agency for each student. See exhibit A for clinical Dallas, Texas requirements. At least ten (10) days prior to the commencement of each period of clinical educational experience, School shall furnish to Facility for each Student participating in the clinical educational program (a) the name and health status report of the Student; (b) a letter of verification stating that the results of a criminal background check and comprehensive drug screen on the Student show no negative, derogatory, or adverse information; and (c) such other data as Facility may request. The health status report shall include evidence that the Student has met the immunization and other health status requirements of Facility and School for participation in the clinical education program. School shall conduct the criminal background check in accordance with applicable law, including, but not limited to, the Fair Credit Reporting Act. School shall assign to Facility only those Students with an active and unrestricted nursing license issued by the State of Texas. Student: See Exhibit A for clinical requirements. Complete Exhibit B. Bayshore Medical Center MSN, DNP UPDATE 8/10/2018

Pasadena, Texas Effective immediately, the afterhours drop box to return student badges had been relocated. The drop box can now be found in the lobby of the Vista building. This is the same office building where the Education office is located. The box has been mounted on the wall just to the right of the mailboxes.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered PLEASE DO NOT return student badges to the security desk. Not all security guards were aware of this process. PLEASE DO NOT slide the badges under the Education office door. Housekeeping will sweep them into the trash.

The best way to return the badge is to return it to the education office.

USA/Faculty: Provide letter of attestation for each student. Student: Complete Exhibits A & B.

Beacon Health System (which Nursing Requests for verification of liability includes physician practices and an insurance (COI) needs to come from Clinical Affairs. acute care hospital) South Bend, Indiana USA/Faculty: Provide at least one month prior to the start of any semester, the anticipated number of students, proposed schedule planned, kind of education experience, academic status of student, names, rank and teaching area.

The university shall have on file and make available upon request:

Tuberculosis Screening A TB Skin test documented in millimeters of measurement current within 12 months of the date of the clinical experience. If the student has a history of a positive TB skin test a Review of Active TB symptoms questionnaire (documenting the student is symptoms free) must also be on file. A TB serology test is also recognized as appropriate. For positive results a TB symptoms questionnaire must also be on file.

Immunization Requirements Rubella- documentation of one dose of live rubella virus vaccine or laboratory evidence of immunity or laboratory confirmation of disease or born before 1957 ( except women of childbearing age who could become pregnant) ACIP 8/28/09 Rubeola- documentation of two doses of live measles virus vaccine or laboratory evidence of immunity or laboratory confirmation of disease or born before 1957 ACIP 8/28/09 Mumps – documentation of two doses of live mumps virus vaccine or laboratory evidence of immunity of laboratory confirmation of disease or born before 1957 ACIP 8/28/09 Td/Tdap – 1 dose Td every 10 years (substitute 1 dose of Tdap for Td age 18-64) Varicella – age 19-64, 2 doses (0,4-8wks) or history of immunity Hepatitis B - age 19-64, 3 doses (0, 1-2, 4-6 months) if the student is at risk for exposure to blood borne pathogens and wishes to have the vaccine. Influenza vaccination. This is mandatory

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Any Student acquiring any of the above named diseases during the course of their rotation must inform their Faculty clinical instructor and Beacon. Records of immunizations are to be provided upon request.

Beaumont Health (to include: Taylor, APRN Royal Oak, Troy, Grosse Pointe, Dearborn, Employees of Employees of Facility ONLY Trenton, Wayne, Farmington Hills, Facility ONLY USA/Faculty: Please complete and sign Addendum Ambulatory) A, per Section 1.3 Scheduling. In consultation with Royal Oak, Michigan Hospital and the applicable Department Program Sponsor (as defined in the corresponding Program Authorization Addendum “A”), School will coordinate and be responsible for assignment of students at Hospital. For each Program, School will provide Hospital with a list of Students that includes names, dates, and hours of assignment and other information specified by School or Hospital at least two (2) weeks before the commencement of the student’s placement at Hospital (“Rotation”). Will plan the student clinical experience in consultation with the Hospital clinical supervisor (for example, nurse manager), at least one (1) week prior to the Rotation, but faculty will have overall responsibility for the educational portion of the clinical experience.

Student: Must complete Addendum B.

Prior to assignment at Hospital, School must provide to Hospital for all students written documentation showing:

Immunity to rubeola, rubella, mumps, pertussis and varicella zoster; and Evidence of Tdap vaccination, or in the alternative, written evidence of declination of the vaccine due to medical reasons consistent with Beaumont policy; and Proof that the students are free from active pulmonary tuberculosis, which shall require a negative PPD (Tb) test, or if positive, active tuberculosis is excluded via physical examination by a licensed physician and a chest x-ray was given within one year of the start date; and Evidence of Hepatitis B vaccination, or in the alternative, written evidence that the students have been offered the Hepatitis B vaccination and have declined; and Evidence of flu vaccination or, in the alternative, declination of the flu vaccination for approved medical or religious reasons consistent with Beaumont policy; and Evidence that students successfully passed a urine drug screen; and Proof that the students have a current Basic Life Support certification from the American Heart Association or acceptable equivalent to Hospital.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Bellin Memorial Hospital, Inc. MSN, DNP Students must complete agency’s application, Wisconsin Background Information Disclosure form, Green Bay, Wisconsin return agency’s HIPAA confidentiality agreement, self-study orientation packet and test must be completed prior to start of rotation. Student must have a Wisconsin Caregiver Background check completed. Contact is Beth Markon: (920) 433-7858 Bellin Psychiatric Center, Inc. Green Bay, Wisconsin Bemidji Area Indian Health Service MSN and DNP USA/Faculty: Provide the Agency, at its (to include: Bemidji Area Health Service, request, objectives. Provide Agency with list of Cass Lake Hospital, Red Lake IHS Hospital, students, units within Agency where they will White Earth Health Center) be assigned, and the dates of the student’s Ogema, Minnesota clinicals. Students: All students must pass a criminal history background check pursuant to P.L. 101-630, the Indian Child Protection and Family Violence Prevention Act, and P.L. 101- 647, the Crime Control Act of 1990, Subtitle E, Child Care Worker Employee Background Check, as well as all regulations promulgated pursuant to such laws. One part of the background check is a fingerprint check. All students must undergo a fingerprint check. Fingerprint results must be cleared prior to the students’ entry on duty. Beth Israel Deaconess Hospital- Nursing Submit list of student(s) and course objectives, course descriptions to Agency. Plymouth Students-Annual Manatoux tuberculin test. Provide Plymouth, Massachusetts annual documentation of influenza immunization or declination form, where student will wear a surgical mask when on-site and while the influenza virus is active in the community. Must have health insurance coverage. Beverly Healthcare BSN, RN-BSN, MSN, DNP Foley, Alabama Billings Clinic USA/Faculty: Notify agency of the planned Billings, Montana schedule for student assignment, including student name, level of academic preparation, length and dates of clinicals. Provide program syllabus and University student handbook to facility. Students: Background check completed within the most recent one year period in any state where the student resided within the last ten years. Drug screen completed with the most recent one year period. Provide evidence of HBV vaccination or evidence of declination.

BJC Hospice DNP, NP USA/Faculty: Provide Facility with the names, St. Louis, Missouri health status reports, including immunizations required and any other pertinent information. Obtain Facility's approval of students and period of clinicals. Must provide evidence of completion and passed the requirements noted in Exhibit 2.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Student: Must complete and sign Exhibit 1- Confidentiality Acknowledgement. Must provide evidence of health insurance to Facility.

Blanchfield Army Community MSN, DNP Hospital Fort Campbell, Kentucky Boca Raton Regional Hospital Undergraduate and See Exhibits A-C. Graduate Nursing Student must have drug screen and background Boca Raton, Florida Programs check within 12 months prior to starting the clinical experience. Boise VAMC AGACNP Boise, Idaho Bon Secours DePaul Medical Center, Nursing Programs USA/Faculty: Complete Attachment B-Attestation. Notify each Facility of its planned schedule of Mary Immaculate Hospital, Maryview Student assignment(s), including the dates of clinical Hospital (All of Hampton Roads experience(s), the name(s) of the Students, and the hospitals and clinics are covered) level of academic and pre-clinical preparation of each Student. Initiate planning for clinical Suffolk, Virginia experiences with the Facilities at least six (6) weeks prior to the start of the clinical experience. Student: Will maintain, insurance coverage for claims made during and after termination of the Agreement, with coverage limits as a minimum of the following: (a) Professional Liability - $2,300,000 per occurrence and $6,900,000 in the annual aggregate, or such higher amounts per occurrence or claim as may be consistent with the Commonwealth of Virginia limitation of recovery in certain medical malpractice actions (the “Medical Malpractice Cap”) and three times the Medical Malpractice Cap in the annual aggregate; (b) General Liability (bodily injury and property damage combined) - $1,000,000 each occurrence, $3,000,000 annual aggregate; and (c) Privacy/Cyber Insurance – $1,000,000 each occurrence, $3,000,000 annual aggregate. Student must provide copy of certificate to both Facility and USA’s Clinical Affairs Department-Beth Collier [email protected] prior to clinical experience. Complete Attachment A-read thoroughly. BON SECOURS ST. MARY’S HOSPITAL OF NURSING USA/Faculty: Complete Exhibit B-Attestation. Notify RICHMOND, INC., Facility (where clinicals will take place) of planned BON SECOURS RICHMOND COMMUNITY schedule of student assignments including the dates HOSPITAL, INCORPORATED, of clinical, name of student and level of academic and pre-clinical preparation for each student. BON SECOURS MEMORIAL REGIONAL Provide educational objectives and evaluation forms MEDICAL CENTER, INC., for each clinical. BON SECOURS ST. FRANCIS MEDICAL CENTER, INC., Students: Must obtain professional liability insurance BON SECOURS AMBULATORY SERVICES, in accordance with the limits established by the LLC, Commonwealth of Virginia Risk Management Plan BON SECOURS VIRGINIA and the Certificate of Coverage., Student MUST HEALTHSOURCE, INC., FORWARD A COPY OF OBTAINED LIABILITY TO USA CLINICAL AFFAIRS OFFICE- BON SECOURS HOME CARE, LLC,

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered CHESAPEAKE MEDICAL GROUP, INC., [email protected] . Must AND acknowledge they have received a copy of the Bon CHESAPEAKE HOSPITAL CORPORATION Secours Health System Code of Conduct. Must d/b/a RAPPAHANNOCK GENERAL maintain health insurance during clinical at facility. Must provide proof of testing for tuberculosis within HOSPITAL 12 months of initiation of clinical. Must complete Exhibit A. Boone Hospital Center NP Students USA/Faculty: Provide Facility with names, health status reports prior to student beginning clinicals. Columbia, Missouri Agency contact: Donna [email protected]. See Exhibit 2 for reference to background check and drug screening. Student: Must provide evidence of health insurance to facility. Complete Exhibit 1. Bortolazzo Group, LLC-ApolloMD Graduate Nursing Must have agreement with facility where clinical Students experience will take place. (Provider Group) USA/Faculty: Provide list of students who will be in Atlanta, GA the clinical experience and the period of said experience. Students must obtain and maintain health insurance coverage. Boulder Medical Center, P.C. MSN, DNP Student must complete Exhibits A&B. Boulder, Colorado Brentwood Hospital Nursing USA/Faculty: Provide names and information pertaining to education and training for students Shreveport, Louisiana enrolled in the clinical experience within a reasonable time.

Students: Must sign a confidentiality agreement which facility will provide. Bronson Healthcare Group BSN, RN-BSN, Students must meet requirements as outlined in MSN, DNP Addendum A prior to the beginning of clinicals. Kalamazoo, Michigan Students please note obligations also outlined in Addendum A. Brooke Army Medical Center MSN USA/Faculty: Forward to the Army Medical Facility the start date. Fort Sam Houston, Texas Contact: Lisa Mitchell lisa.j.mitchell8@[email protected] 210-916-4652 Brookwood Baptist Health Nursing and Nurse Agency does not sign LON. Please keep a copy Practitioner of the student application they provide to the (Brookwood Baptist Medical Center, student in lieu of the LON. Cititzens Baptist Medical Center, Princeton Baptist Medical Center, BSN students: Request Attachments A-C prior to clinical. They are Statement of Responsibility, Shelby Baptist Medical Center and Confidentially Statement, and Background Walker Baptist Medical Center) Screening Attestation.

Birmingham, Alabama NP students: Complete Exhibits A-C prior to clinical. Brookwood Physician Practices, LLC Nursing Course Coordinator contact Clinical Affairs before directing students to obtain LON. (covers Cahaba Heights, Homewood, Hoover, Narrows, Oak USA/Faculty: Complete Exhibit D-Attestation. Mountain, Vestavia, Student: Complete Exhibits B & C. Inverness, Greystone Internal Medicine) Birmingham, Alabama Broward Health Graduate Nursing See Student Requirements Page. Fort Lauderdale, Florida

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered https://www.browardhealth.org/orientat ion/orientation-pages/students-interns- and-instructors-orientation

Must provide to Agency results of Student’s background check. Butler Memorial Hospital Nursing Programs See Exhibit C-Facility Specific Requirements. Submit to the Facility, at least sixty (60) days prior to Butler, Pennsylvania commencement of the Program, a description of the types of clinical experiences/fieldwork needed, the dates during which the clinical experience/fieldwork will be needed, the number of Students expected to participate in the program and the names, professional credential and evidence of current licensure of the Faculty who will supervise the Students.

Each Student has completed all necessary paperwork and education prior to commencement of any Student activity at the Facility.

Agency Name Programs Agency Requirements Covered Cabell Huntington Hospital BSN, RN-BSN, MSN, See Attachment 1 for additional requirements. DNP Huntington, West Virginia USA/Faculty: Will submit to Facility three weeks prior to the beginning of each clinical, a schedule indicating the number and names of students who will be participating and the name of the faculty who will be supervising the students during their clinicals. Cache Valley Hospital Nursing USA/Faculty: Complete Exhibit C. Student: Must complete Exhibits A&B. Must pass a North Logan, Utah medical examination at least once a year or as otherwise required by Utah law. TB skin test within the past 12 months or documentation as a previous positive reactor. Capital Area Human Services Undergraduate and Student: Graduate Nursing All students shall be free of tuberculosis in a Baton Rouge, Louisiana communicable state as evidenced by either: a negative purified protein derivative skin test for tuberculosis, five tuberculin unit strength, given by the Mantoux method; a normal chest X-ray, if the skin test positive; or a statement from a licensed physician certifying that the individual is non-infectious if the X-ray is other than normal. The student shall not be denied their practicum experience solely on the basis of being infected with tuberculosis, provided the infection is not communicable. Abide by the laws and ethical codes that govern the practice of nursing in the State of Louisiana, the CAHS Code of Ethics, and the Louisiana Code of Governmental Ethics.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Pay for and obtain an original Louisiana State Police background check and fingerprint report to provide to the Agency according to the Agency’s instructions. Attend the Agency’s general orientation and the facility- level orientation at the assigned location of the practicum, as scheduled by the Agency.

Carilion Clinic (covered entities are: MSN, NP, DNP USA/Faculty: Each Student and Faculty member must Carilion Franklin Memorial Hospital, meet with the criteria set forth in Addendum B within 60 days prior to clinicals. Contact the facility in writing at Carilion Healthcare Corp, Carilion least 3 weeks in advance of a new placement. Must Medical Center, Carilion New River forward student names at least two weeks prior to their Valley medical Center, Carilion Stonewall arrival. Jackson Hospital, Carilion Tazewell Community Hospital, Inc, and CHS, Inc.) Student: Student must meet with the requirements set Roanoke, Virginia forth in Addendum A. CarolinaEast Health System (to NP Nurse Practitioner Students Student: Must complete Exhibit B. Provide all requested include CarolinaEast Physicians) documentation of immunizations to facility prior to New Bern, North Carolina clinicals. CarolinaEast Medical Center and NP Preceptor must be employed by Emergency Medicine Physicians. Emergency Medicine Physicians Nurse Practitioner Students of Craven County (3-way Student: Must complete Exhibit B. Provide all requested agreement) documentation of immunizations to facility prior to clinicals. New Bern, North Carolina

Carolina’s Emergency Group Graduate Nursing USA Must have agreement with facility where Students student will physically be in a clinical setting. (ApolloMD) USA/Faculty: provide to group a list of the students who Morrisville, North Carolina will be participating under the agreement. Carl R. Darnall Army Medical Nursing Center Fort Hood, Texas Cass Regional Medical Center Undergraduate and Graduate Nursing Harrisonville, Mossouri Catawba Valley Medical Center RN-BSN, MSN, DNP USA Faculty: Upon request please provide the following; • Objectives of the Experience Hickory, North Carolina • Course Titles • Number of Students • Dates, days and times of Experiences • School’s Faculty names/qualifications • Departments to be utilized

Student: Must have appropriate health insurance. Must have a North Carolina criminal background check prior to placement, must include a minimum of 7 years. Cathedral Place Apartments BSN, MSN, DNP Mobile, Alabama

CDH-Delnor Health System (to Nursing USA must provide evidence that student has met all requirements of CPR certification, Hepatitis B include: Central DuPage Hospital, vaccination, and OSHA compliance for prevention of CDH Cancer Center, Bartlett blood borne pathogens and TB. Student must Convenient Care, Bloomingdale comply with Program Specific Requirements: Convenient Care, Glen Ellyn Background Check and Drug Screen as outlined in

Convenient Care, Naperville Exhibit C.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Convenient Care, St. Charles Convenient Care, and Wheaton Convenient Care) Winfield, Illinois Renewal in process-set to expire 12/31/2018 Centegra Health System (covers RN-BSN, MSN, DNP PLEASE SEE EXHIBIT C-Agency Requirements. Students must obtain prior written approval of the Site All inpatient and outpatient prior before publishing any material relating to clinical locations of Centegra Health experience. System hospitals, including Centegra Physician Care locations). Woodstock, Illinois Centra Health MSN, DNP Students utilizing this agreement must submit a copy of their own personal professional liability Lynchburg, Virginia insurance to the Clinical Affairs department, through their USA Faculty, at the USA CON and the agency before beginning clinicals. This insurance must be obtained in the amounts indicated on the attachment. Student also must provide copy of health insurance coverage to agency.

USA/Faculty: Submit a schedule of students name to the Unit Manager of the appropriate area where student(s) will be assigned seven days prior to clinicals. Please provide, course description, course objectives, course schedule, number of students (agency contact: Roberta Vick, Managing Director, Professional Development. [email protected]

CentraCare Health (also covers: Nursing USA/Faculty: See Exhibit 2-Documentation evidencing CentraCare Clinic compliance with these requirements must be on file and CentraCare Health – Long Prairie provided to Agency within 24 hours upon Agency’s CentraCare Health – Melrose request. CentraCare Health – Monticello CentraCare Health – Paynesville CentraCare Health – Sauk Centre CentraCare Surgery Center The Saint Cloud Hospital St. Benedicts Senior Community) St. Cloud, Minnesota Central Alabama Veterans BSN and MSN Healthcare System Montgomery and Tuskegee Alabama Central Arkansas Veterans BSN, RN-BSN, RN- BSN, RN-BSN, RN-MSN, MSN, and DNP MSN Healthcare System Little Rock, Arkansas Central Carolina -CIM, LLC, NP Nurse Practitioner Students Only USA/Faculty: Complete the Exhibit A-Attestation Central Carolina-IMA, LLC Tenet Statement and return to Monica Gilkinson: email- Central Carolina Physicians, Inc., [email protected] phone 919-774-2290 ; Central Carolina Physicians- secretary phone 919-774-2108. Upon request participate in the Clinic's Quality Assurance and related programs.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Sandhills, LLC, North Carolina Students: Must complete Exhibit B-Confidentiality Agreement and Statement of Responsibility. Must be Community Family Medicine, LLC educated with OSHA Compliance to include provisions and any other physician practice of the hepatitis B vaccination or documentation of acquired by Tenet Healthcare declination in accordance with the Regulations. Must view a videotape (provided by facility) regarding Clinic's Corporation patient information privacy policies and practices and Sanford, North Carolina achieve a passing score. Must read the facility's Standards of Conduct available at http://www.tenethealth.com/about/ethics-compliance. Graduate Nursing Student contact is Ginger Porter [email protected]. Central Carolina Hospital Programs The student will need to request an account with (part of the Tenet Healthcare LifeTalent. Corporation-DLP) School shall provide to Hospital not less than one (1) month prior to the commencement of each Student’s Sanford, North Carolina rotation: (i) the name of each Student and a proposed schedule of assignment to the Clinical Sites; (ii) the expected level of experience to which School proposes each Student will be assigned; (iii) the expected learning objectives of each Student; (iv) a summary of each Student’s education and clinical experience and field work; (v) a background check of the Student upon entry or reentry into the program and (vi) such other information as Hospital may reasonably request. Central Florida Healthcare, Inc. BSN, RN-BSN, MSN, Agency may put limit on amount of students per DNP semester. Winter Haven, Florida Central Iowa Hospital, Corp. Nursing USA Faculty: Must give each student participating in clinicals at facility a Student Orientation Manual. d/b/a UnityPoint Health - Des Instructors will need a valid license in the state of Iowa to Moines practice nursing or any other required license application Des Moines, Iowa to the position. Clinical Professional Development # 515- 241-5576. Student: Will have completed an Iowa Department of Public Health approved Child & Dependent Adult Abuse training program. Central Maine Community Nursing College (CMCC) Auburn, Maine Central Plaza Towers Mobile, Alabama

Centura Health (to include: Avista BSN, MSN, DNP Agency utilizes MyClinical Exchange. Cost to student is Adventist Hospital, Porter Adventist $36.50 per year. USA/Faculty: Shall provide applicable curricula to Hospital, Littleton Adventist Hospital, Facility -Angela Shopp - [email protected]. Parker Adventist Hospital, Penrose Shall provide Facility with records of student's physical Hospital, Penrose Community Hospital, exam, immunization status, and other medical tests; St. Francis Hospital, St. Anthony Summit including but not limited to mumps titer, measles titer, MC, St. Mary-Corwin MC, St. Thomas rubella titer, TB test, hepatitis B, Polio, varicella, and More Hospital, Porter Hospice, Mercy tetanus. Provide documentation of necessary training in Regional MC, Centura Home Care and OSHA regulations, HIPAA requirements, and BLS Hospice, Centura Senior Life Center) certification. Must submit letter to Facility, verifying that each student's criminal background check is acceptable Englewood, Colorado to JCAHO standard and Facility's standards.

***FOR MERCY REGIONAL MEDICAL CENTER*** see below

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Program Coordinators, please give as much notice as possible when a student may be coming to our facility. Once a student has contacted a provider who has agreed to supervise or proctor their rotation here, the next step is to contact me with the student contact information at that time I will send the student our “Student Rotation Application”, “Student Roles and Responsibilities” form, and “Documentation Checklist”.

When contacting the facility I ask that the program coordinators include:Proof of Insurance (Company and Limit), A letter of good standing (including confirmation of background check), OSHA and HIPPA training verification, PEG student photo, Current certifications or licenses (BLS, ACLS, PALS, RN, FNP, NP, etc.), Copy of current immunizations (Flu and TB)

Charleston Dorchester Mental Nursing Students must complete the following annually: South Carolina Sexual Offender Registry Background Health Center (SCDMH) Check. Charleston, South Carolina South Carolina Law Enforcement Division (SLED) Criminal Records Check.

Charlotte Mecklenburg Hospital This agency not This agency not available as a clinical site for any available as a USA Student (including employees of CHS). This is a Authority d/b/a Carolinas clinical site for any HARD NO due to a legal impasse. DO NOT HealthCare System (Covers ALL USA Student APPROACH THE AGENCY or USA’s CLINICAL CHS facilities) (including AFFAIRS DEPARTMENT! employees of CHS). DO NOT approach the agency with a two-page Charlotte, North Carolina This is a HARD NO agreement request. 5/15/2018-Their name has due to a legal changed to Atrium Health. impasse. DO NOT APPROACH THE Ruling of no agreement still AGENCY or USA’s stands, as their requirements CLINICAL AFFAIRS DEPARTMENT! have not changed. DO NOT approach This agency not available as a the agency with a clinical site for any USA two-page agreement request. Student (including employees of CHS). This is a HARD NO due to a legal impasse. DO NOT APPROACH THE AGENCY or USA’s CLINICAL AFFAIRS DEPARTMENT! DO NOT approach the agency with a two-page agreement request.

Chattanooga-Hamilton County BSN, RN-BSN, Hospital Authority d/b/a Erlanger MSN, DNP Health System Chattanooga, Tennessee Cherokee Nation Nursing Student: Must complete attachment A. Must provide a negative drug test within 90 days prior to start at clinical Tahlequah, Oklahoma site.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Renewal in process-set to expire on 9/30/2018

Chester Regional Medical Center Nursing Students must complete Addenda 4-6. A negative TB skin test within the past year or, in the Chester, South Carolina event of a positive TB skin test, a chest x-ray within the past three (3) years; OR provide evidence of no TB disease per negative result of interferon-gamma release assay blood test (T-Spot or Quantiferon Gold) within twelve (12) months of student activity at Agency.

Chickasaw Nation Medical Nursing Students: a complete Hepatitis B vaccination series (series of Center through the Chickasaw three.); Department of Health negative PPD or chest x-ray; Ada, Oklahoma MMR vaccination( s) or positive titer(s); and a written verification of varicella history, varicella vaccination or a varicella titer by a physician or a physician 's designee. Students that they are not permitted to perform any of the following: (i) double-check on medications or blood products; or (ii) begin or discontinue blood products, chemotherapy, or experimental drugs and therapies. Children’s Health System of Nursing and See Exhibit A and B Arrangements for clinicals must be made 6 months prior Texas (covers all facilities within Graduate Nursing Programs to the start of each academic term. network, including Dallas and Plano) Provide Agency with the following written information three (3) weeks prior to the start of each practicum: Dallas, Texas Specific days and hours students will be on patient units or service areas; Names of students and responsible faculty; Documentation of liability insurance for students Provide objectives of the practicum

Submit written verification on University letterhead that each student complies with the current Community Standards for Drug Screening, Background Checks, and Immunizations. University will be audited regularly to ensure it can provide proper documentation to support its attestation letter, including providing proof of vaccines, drug tests, background checks and immunizations as set forth by the Dallas/Ft-Worth Hospital Council Foundation – Community Standards for Drug Screening, Background Checks and Immunizations. Children’s Healthcare of Atlanta BSN, RN-BSN, MSN, Students must follow the following procedure set up by DNP the agency. (covers Egleston and Scottish Once a preceptor has been identified, the student is Rite) to contact the placement coordinator via email with the Atlanta, Georgia following information: o Name o School o Program type o Dates/Semester of experience o Preceptor's name/department

Advanced Practice Nursing student requests: Abby Leonard MSN (non-NP) requests: Jennifer Bay

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered

· Abby/Jennifer confirms the school agreement and preceptor then send the student a pre-credentialing form to complete · Student submits pre-credentialing form · Abby/Jennifer submits student's name to SYMPLR (online credentialing system), which triggers email invitation to student from SYMPLR to start the credentialing process · Student completes all pre-clinical credentialing requirements (formerly provided via Exhibits A, B-1, and C). · Abby/Jennifer confirms student has completed all requirements in SYMPLR (green light compliance status) · If student has green light status, student will receive final confirmation from Abby/Jennifer with instructions on how to obtain student badge

There is a cost of $49/year/student, which covers a background check and review of student documents. We do require a current drug screen which is not covered under that price. If a student has a current drug screen report (within the last 2 years) that complies with our requirements (all detailed in SYMPLR for the student), they can use it. If they do not, we can give them directions on how to obtain.

Children’s Hospital RN, RN-BSN, USA/Faculty: Update facility on program of clinical MSN, NP experience. Send name and bio of each student to New Orleans, Louisiana facility at least four weeks before the beginning of clinical experience. Student: Will be given state required health tests. Must provide own health insurance. See Holiday schedule that must be followed. Children’s Hospital Pediatrics Washington, D.C. Children’s Hospital & Clinics of USA/Faculty: Please reference Exhibit A-Operating for Minnesota Clinical Education Agreements. Provide Facility with list Minneapolis, MN of students participating in the clinical experience, along with the units’ locations and dates of each participation. Student: Must sign a Confidentiality Statement provided by Facility. Must provide Facility with results of health examination with updated immunizations and to include a mantoux test or chest x-ray and verification of immunity for rubeola and rubella. Children’s Hospital Medical RN-BSN, MSN, DNP For any student who is interested in going to Akron students. Children’s Hospital for their preceptor program, the first Center of Akron step needed is to fill out a redcaps survey at, Akron, Ohio http://www.akrondb.org/surveys/?s=7ZYnLq

Contact: Laura Abels is our Education Coordinator in the Advanced Practice [email protected] USA/Faculty: Provide appropriate evidence that student participating in clinicals has satisfied the facility's infection control and wellness policies, to include immunizations, yearly flu vaccine, and urine 10-panel drug screen. Provide attestation or evidence of compliance at least 2 weeks prior to clinicals. Each Semester needs a completed attestation.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Student: Student will pay a $20 fee for their badge if not returned. Must submit fingerprints to the Bureau of Criminal Identification and/or Federal Bureau of Investigation for evaluation prior to the start of clinicals. Submit this documentation to the USA CON Clinical Affairs department through your USA Faculty.

Children’s Hospital Medical Practice Corporation New Orleans, Louisiana Children’s Hospital of Alabama Nursing Students SEE Student Guidelines for dates to request site. Students will not be able to contact the facility for (all primary offices are covered if placement. Requests must be made for the following owned by Children’s semester in advance according to the dates within Hospital)Birmingham, Alabama the student guidelines.

Nursing Preceptor & NP Agreement Exhibit A (along with other forms) to be completed by faculty and student prior to placement. FACULTY, PLEASE NOTE: Our one page agreement is not required. Children’s Hospital of Alabama has a Form of Preceptor Assignment (Exhibit 1.2) this form does not require USA Faculty signature. Form Exhibit 1.2 will be accepted in lieu of our one page agreement. USA does require a signed copy of Exhibit 1.2 for our records.

Any nurse practitioner student who wishes to have a preceptorship at Children's must submit the request form to (available in the attachments) TERA STALLWORTH [email protected] by the following dates:

May 15th for placement in the Fall Semester September 15th for placement in the Spring Semester February 15th for placement in the Summer Semester Children’s Hospital of the King’s NP NURSE PRACTITIONER STUDENTS ONLY USA/Faculty: Provide a detailed description of the Daughters, Inc. objectives and specific fieldwork experience to be Norfolk, Virginia provided in the program and any other information required by facility within 30 days of clinicals. USA responsible for Blood Borne Pathogens post exposure follow-up.

Student: Will complete the student profile attachment.

Agency Contact:Linda Grasmick Nursing Practice and Education Department 757-668-8463 [email protected]

Children’s Med Services, Florida RN-BSN, MSN, DNP Department of Health

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Panama City, Florida Children’s Mercy Hospital and BSN, RN-BSN, RN- MSN Clinics Kansas City, Missouri Children’s Rehab Services Mobile, Alabama Christian Medical Ministry of Undergraduate RN-BSN, MSN, DNP South Alabama Mobile, Alabama Renewal in process-set to expire 11/2/2018 Christus Good Shepherd Medical Graduate Nursing Programs Center (covers Longview and Marshall) Longview, Texas Christus Health Northern Nursing Louisiana (covers all of Northern Louisiana sites-Highland Medical Center, Bossier Emergency Micro, Cancer Center) Shreveport, Louisiana Christus Santa Rosa Health Care Graduate Nursing San Antonio, Texas Christus Spohn Health System BSN, RN-BSN, MSN, Faculty must provide facility with written curriculum, DNP evaluation methodologies and a set of Student Corp. objectives and complete Exhibit A. Corpus Christi, Texas Christus St. Frances Cabrini Hospital Alexandria, Louisiana Renewal in process-set to expire 11/1/2018

Christus-St. Vincent Regional BSN, MSN, DNP USA/Faculty: Provide Facility with a written curriculum, Medical Center evaluation, methodologies, and a set of Student objectives. Provide a schedule for Students specifying Santa Fe, New Mexico hours, days of the month, months of the year during which Student will be in clinicals (Exhibit A). Notify Facility within 48 hours when/if Student becomes excluded from a federal health care program.

Christus Trinity Clinic Nurse Practitioner Students Longview, Texas Renewal in process-set to expire 7/1/2018 Choctaw Nation of Oklahoma Nursing USA/Faculty: Provide roster of names of the designated Instructors and Students along with a rotation schedule Health Services Authority to person designated by Facility at least two weeks prior Talihina, Oklahoma to clinical experience.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered

Student: Provide verification of Tetanus in last 10 years or booster of TDaP. Negative urine drug screen. Must have a current BLS certification for adult, child, and infant. Encouraged to maintain medical coverage.

Cincinnati Children’s Hospital Faculty and Students please see Exhibits B & C for agency requirements. Medical Center Also please note, student must complete and sign (if Cincinnati, Ohio applicable) the following: Confidentiality Agreement System Access Confidentiality Agreement Patient Protected Health Information Access Designation Student Orientation Manual Receipt Certificate of Completion for HIPAA Training Course provided by CCHMC

This agreement is ONLY in effect for Cincinnati Children's Hospital Medical Center employees. Citrus County Health Department BSN, RN-BSN, RN- MSN Lecanto, Florida City of Hope National Medical USA/Faculty: Provide list of specific courses and course objectives and desired units for placement at facility. Center Provide 60 days prior to commencement of experience Duarte, California or semester, the number and level of students to be assigned to facility for clinical experience. This will be subject to approval by facility prior to experience. Provide evidence of student health status to Hospital before the beginning of the rotation. Such evidence shall include, without limitation: the results of an annual physical exam; negative two step tuberculin skin test; IGRA blood test or negative chest x-ray if skin test is positive, and proof of positive skin test; evidence of immunity against varicella, mumps, rubella and rubeola; and proof of current Tdap and Hepatitis B vaccination. SEE OSHA Requirements, via attachments in Sakai.

Student: Facility requests students to submit information related to their prior experience, to include job or level of experience descriptions and specific information regarding competency. Must have annual physical exam. Must provide evidence of health insurance coverage. Familiarize themselves with the foregoing privacy and security laws and facility policies applicable to health information. Provide written clearance from physician before resuming participation in experience if returning after an absence caused by injuring or significant illness greater than 3 days of off-duty.

City of Mobile Undergraduate Mobile, Alabama and Graduate Nursing Students CJW Medical Center Nursing Student: Complete Exhibit A & B. Must pass a medical MSN and DNP examination acceptable to Hospital prior to clinicals (Chippenham & Johnston-Willis) within at least one year. Richmond, Virginia

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Clay County Medical Corporation NP Must complete the Student Clinical Education Agreement. Must complete Healthcare Criminal History d/b/a North Mississippi Medical Background Affidavit. Must provide signed affidavit that Center-West Point he/she does not have a disqualifying event under the law West Point, Mississippi or submit to fingerprinting in order to comply with the requirements of Mississippi Code (See Health Sciences Advisory form). Each student shall submit proof and be considered immune by providing the following: (1) Documentation of having received two live measles containing vaccinations after their first birthday, (2) documentation of initial two step and up to date TB skin test followed by annual testing, (3) documentation of three Hepatitis-B vaccinations or in process, (4) documentation of having received a tetanus containing vaccination within the past 5 years and a prior tetanus/diphtheria/pertussis (5) documentation of flu vaccine October-March or alternatively require student to sign a waiver and wear a mask when in a NMHS owned or operated facility. Medical contraindications to vaccines and positive TB skin test follow-up must be reviewed by NMMC-West Point-Tupelo Employee Health.

Each student enrolled in the Clinical Education Program will not be an employee of NMMC-West Point within the meaning of the Mississippi Workers' Compensation Law, and will not be receiving any monetary compensation from NMMC-West Point during the time of the training at NMMC-West Point;

Coastal Family Health Center Undergraduate and Biloxi, Mississippi Graduate Students (covers ALL locations) Collaborative Care Services, Inc. Nurse Practitioners Agency employee’s potential preceptors for in- and its affiliates (previously United home care.

HealthCare Services, Inc. d/b/a Evercare Students must complete attachments prior to Georgia) clinicals-See faculty Norcross, Georgia Collaborative Care Services, Inc. BSN, RN-BSN, RN- USA/Faculty: See Exhibit A for Roles of USA per the MSN agreement. Provide written objectives to facility. Notify (Optum Health) agency of student’s hours in clinicals. also covers (Optum Health in PA, Student: Must Read and Sign Exhibit B. Facility will Southwest Medical Associate provide for the orientation of students to its rules, regulations and policies. clinics including urgent care in Southern NV) West Chester, Ohio Collaborative Care Services, Inc. Nurse Practitioner Student must maintain health insurance and provide proof of health insurance. Student must complete Exhibit (House Calls-Optum-covers all A. their practitioners in each state)) Horsham, Pennsylvania

Columbia Area Mental Health Nursing Center (SCDMH) Columbia, South Carolina

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Columbia County-Florida USA/Faculty: Provide a schedule naming the students to attend and planned attendance dates to facility (Marjorie Department of Health [email protected]). Lake City, Florida (Agency requesting to update agreement-temporary hold on clinicals until complete) Columbus Regional Health Nursing Student: Complete Exhibits A&B. (covers the Medical Center dba,Midtown Medical Center, Hughston Hospital, Inc., dba Northside Medical Center) note: there is a supplemental agreement that will cover preceptors employed by the Southern Emergency Group, LLC. Columbus, Georgia Comanche County Hospital USA/Faculty: Provide clinical instructor name and student roster at least10 days prior to clinicals. On site Authority instructors must have unrestricted license in Oklahoma. Lawton, Oklahoma Student: Must have negative drug screen performed by a laboratory licensed by the Oklahoma State Department of Health. Students cannot perform any of the following: double-check on medications or blood products; or begin or discontinue blood product, chemotherapy, ore experimental drugs and therapies. Cannot accept orders from physicians or other health care professionals in person or by phone. Commonwealth Health MSN, DNP USA/Faculty: Provide names and social security numbers of each student to Agency. Agency contact: Corporation Trish [email protected]. Bowling Green, Kentucky Student: Must attend either the CHC New Employee Orientation, Abbreviated Employee Orientation program. Must complete a Student Application, Statement of Understanding and any other applicable documents provided by Agency to the CHC Human Resources Department. Recommended to obtain health insurance. Provide proof verifying completion of the TB Risk Assessment form including TB screening method determined appropriate for each student.

Community CarePartners, Inc. BSN, RN-BSN, MSN, USA Faculty: Please see Appendix I, if instructing DNP students at agency. Provide written notice to agency of Asheville, North Carolina practicum and affiliation assignments at least 60 days Renewal in process-set to prior to clinicals. Develop and implement a program for post exposure evaluation and follow up. expire on 9/30/2018 Students: OSHA required education in bloodbore pathogens, personal protective equipment, and other measures designed to avoid exposure to bloodborne pathogens. TB test completed on annual basis.

Community Health Connection, Undergraduate and Graduate Nursing Inc. Tulsa, Oklahoma Community Health Network (to BSN, RN-BSN, RN- USA/Faculty: Provide facility with the anticipated MSN number, type of schedule planned, kind of educational include: Community Hospital North, experiences desired and academic status of students.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Community Hospital East, Community Facility must approve the number of placements and Hospital South, and Community Home scheduling of students. Must provide any other pertinent . information requested by facility. Responsible for Health) documentation of students yearly participation in Indianapolis, Indiana education concerning OSHA Tuberculosis, OSHA Blood Borne Pathogens, CPR and any other educational component as requested by facility. Agency Contact: Jaima Foresman-317-621-7973.

Student: Provide evidence of physical examination showing good general health, coverage of health insurance policy, proof of immunizations, current (yearly) results of tuberculosis (skin test and/or x-ray) tests assuring the student is free from active infection of TB, proof of Hepatitis B immunization or documentation showing student has been informed of the risk of Hepatitis B and declined immunization. Must sign a confidentiality agreement as provided and required by facility. Community Hospital of the Nursing Student Checklist must be completed by Clinical Affairs. Monterey Peninsula Monterey, California USA/Faculty: Provide to Hospital, student’s clinical/field experience, name, bio data, health status, proof of immunity to measles and rubella, proof of PPD and other appropriate information 8 weeks prior to clinical experience. Comprehensive Medical Undergraduate and Group/NPOC-Nurse Practitioner Graduate Nursing On Call Pensacola, Florida Concord Hospital Graduate Students See Attachment A-Responsibilities of Student. Provide to Concord Hospital a description of the program Concord, New Hampshire and internship requirements.

Provide to Concord Hospital the faculty contact person and University of South Alabama program contact information. Provide Concord Hospital with a schedule of planned student assignments including dates, names and numbers of students.

Provide to Concord Hospital verification of the following for each student: Proof of individual health insurance; Verification of completed criminal background check or signed waiver if under age 16; Professional Liability insurance Proof of the following immunizations or related documentation: Negative two-step tuberculin skin test within the past year or, if test is positive, a health care provider note documenting medical clearance; Completed hepatitis B immunization series with laboratory confirmation of positive antibody; signed waiver or documentation of non-converter status; Varicella immunity e.g. documentation of two doses of vaccine, laboratory confirmed immunity, or healthcare provider diagnosis of chickenpox or shingles (herpes zoster); Rubeola immunity e.g. documentation of two doses of vaccine or laboratory confirmed immunity;

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Rubella immunity e.g. documentation of one dose of vaccine or laboratory confirmed immunity; Mumps immunity e.g. documentation of two doses of vaccine or laboratory confirmed immunity; Pertussis vaccine e.g. documentation of single dose Tdap or Dtap. nfluenza status (received, or declined and reason). Inform students prior to the experience that they are to comply with the duties and responsibilities listed in Attachment A of this Agreement and incorporated herein by reference. Conemaugh Memorial Medical MSN, DNP 2017 Update See attachments Updates include: Center Johnstown, Pennsylvania Clearance Process Packet: Renewal in process-set to CSA form is valid for one full year from date of expire 10/7/2018 signature

Database template:

# of Hours per Clinical Rotation column added to database template

Statement added to column B of database template:

It is imperative that this column be completed for ALL students and faculty who are CHS employees. With the implementation of Conemaugh Connect* a Workflow profile is created by MIS for employees. This profile may need adjusted based on an employee's position within CHS and student status.

*CHS Clinical Documentation System

Handbook: Page 10 of Handbook regarding Conemaugh Connect. Update: New policies affecting Conemaugh Health System employees and CHS affiliating schools students have been implemented. Please send all clearance letters to: Diane Kennedy, HR Assistant, HR Dept. [email protected]

Attachments: - Updated clearance letter templates. Please use these letters from this point forward. - CHS TB Policy for employees and students - Updated Conemaugh Corporate Care Student Fees - Instructions and link to access MMC online education

Effective, July 1, 2014, these additional health tests are now included in the affiliating schools student clearance process: Influenza vaccineo If student start date at CHS is during flu season, 10/1 - 3/31, student must have vaccine before starting their rotation.o If student start date at CHS is outside of flu season, student must acknowledge CHS influenza policy and agree to be immunized by 11/15 of each year. Policy allows exemptions for both medical and religious reasons. More

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered information to come on the exemption process. Mumps immunization (if rubella/rubeola vaccination is needed) For clinical students with risk of exposure to blood borne pathogens: Hepatitis B: Must have immune titer or be immunized. For students rotating in Maternity/Nursery, NICU, Pediatrics, or DEM. Tdap – receive one time dose of Tdap if no written documentation of previous immunization.

USA/Faculty: Provide Hospital names of all students beginning clinicals. Must notify unit supervisor as far in advance as possible, but no less than twenty-four hours in advance, when students will not or cannot participate in clinicals. Must provide sufficient copies of course materials to supervisor of the units. Verify in writing for each student has had a health examination, 2 step PPD, 5 panel negative urine drug screen, rubella, rubeloa, and varicella zoster titers from a federally approved site. Provide in writing student has CPR certification. Must provide all students with HIPAA and infection control education. MMC does not permit discharged employees to return to MMC in an affiliating school instructor role nor in a student role Student: Must have Criminal History Record Check completed and cleared within the last year before clinicals. Must have child Abuse clearance within the past year before beginning clinicals. Recommended student purchase a health insurance policy. Must sign Exhibit A. Conemaugh Physician Group Nursing Students USA/Faculty: Provide name of student beginning a clinical experience. Notify unit supervisor as far in Johnstown, Pennsylvania advance as possible but no less than 24 hours in advance, when student will not or cannot participate in the clinical experience. Provide copies of course materials to preceptor. Student: Complete Exhibit A. Must have clear Criminal History Record Check within the last year before starting the clinical experience. Must have Child Abuse clearance within last year before starting clinical experience. Student must provide in writing that they have had a health examination within 2 years of the student’s start date of rotation, 2-step PPD within one year of start date of rotation, minimum 5-panel negative urine drug screen within 30 days of start date of rotation, and rubella, rubeola and varicella zoster titers, mumps immunization (if rubella/rubeola vaccination is needed) tetanus within 10 years of start date of rotation and a one time dose of Tdap for students rotating in Maternity/Nursery, NICU, Pediatrics, or DEM, if no written documentation of previous immunization from a federally approved site. School will also verify to Clinic in writing that each student has had an influenza vaccine, if the student starts rotation when vaccine is available, or agrees to be immunized by 11/15 of each year and a Hepatitis B immune titer or be immunized. Agency strongly recommends student has a health insurance policy. Confluence Health (Central Graduate Nursing Clinical Experience must be approved by the facility. Students To include but not limited to; Two weeks prior to clinical Washington Hospital and experience, (i) the number of Students that will Wenatchee Valley Hospital) participate in a Clinical Practicum; (ii) the departments of

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Wenatchee, Washington the Hospital to be utilized for assignments to the Students; (iii) the dates and hours of each Student’s assignment to the Health System for a Clinical Practicum, including the dates of vacations and holidays to be observed. Such determinations will take into account the needs of the School for the placement of Students in the Clinical Practicum, the maximum number of Students for whom the Health System can provide a desirable clinical education experience, the needs of other schools requesting the Health System provide a Clinical Practicum, and any other constraints of the Health System. and, (i) Tuberculosis Screening and Disease Immunity and Vaccinations information as requested on the Student/Instructor Medical Information form to be in compliance with Confluence Health Policies; (ii) Legal first and last name, date of birth, address and telephone number; (iii) Current (within 12 months) negative background check including: seven (7) year nationwide criminal history, Office of Inspector General/Health & Human Services, and WSP checks; (iv) Current (within 12 months) negative drug screen pursuant to Central Washington Hospital Student Program Policy OF-25. Please complete the survey at https://www.surveymonkey.com/s/LX9NJ9C

Contact: Meagan Kovanen - [email protected]

Connecticut Children’s Medical Nursing USA/Faculty: Complete Exhibit B-Attestation, Provide Agency with list of number and name of students, along Center with name of Instructor. Hartford, Connecticut Student: Complete Exhibit A-Confidentiality Agreement. Students s have a background check that includes (i) a criminal history including felonies and misdemeanors for each state in which the student has lived, worked, or attended school; (ii) national sex offender registry check; and (iii) FACIS Level III sanction check (the “Background Check”), at the expense of each Student, performed no more than forty-five (45) days prior to the start of the academic year in which Student will complete the Clinical Practicum at Connecticut Children’s. Conroe Regional Medical Center Nurse Practitioner USA/Faculty: Complete Exhibit C-Attestation. Contac CNL, CNS, Exec agency’s contact to identify each program participant Conroe Nurse Admin, Nursing and to give any other requested information for the Informatics, Nurse experience. Educator Minaz Dungor [email protected]

Student: Complete Exhibits A&B. Must have Tuberculin skin test performed within the past 12 months or documentation of pervious positive reactor. Must obtain a background check prior to each Semester. Continuing Care Hospital, Nursing Students must sign Exhibit A and B. Inc.(South Dakota University) Lexington, Kentucky

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Cook Children’s Hospital (to MSN, DNP and USA/Faculty: Please see Exhibit A Background APRN Certificate Check/Drug Screen for agency requirements per the include the Physician Network) agreement. Fort Worth, Texas Cooper University Hospital Attachments to be completed by faculty and student Camden, New Jersey Corizon, LLC (ASPC Perryville in Nursing Student: Must complete exhibit A. Goodyear Arizona -Arizona Department of Corrections) Brentwood, Tennessee Covenant Community Care All Nursing Programs Students must complete an online application from the facility’s website Detroit, Michigan http://covenantcommunitycare.org/2017/08/04/shadow/. Covenant Hospice BSN, RN-BSN, MSN, Student must have confidentiality statement signed DNP Daphne, Alabama and witnessed. Flu vaccination (Nov.1st-March 31st). TB Symptom Staff Questionnaire and no evidence of Pensacola, Florida (corporate persistent cough. Background check less than one ofc.) year old. Drug Screen less than one year old. Must complete Student Intern Data Record available from the contracts office. Faculty, please see updated Student Intern Data Record.

Crescent Community Clinic Undergraduate and Graduate Nursing Spring Hill, Florida Crestwood Medical Center Nurse Practitioner USA/Faculty: Complete the Pre-Clinical Requirements document. Huntsville, Alabama See Addendum 1 for patient care to be provided by students. Obtain written documentation from Students and staff prior to referring them to Facility: a negative TB skin test within the past year or, in the event of a positive TB skin test, a chest x-ray within the past three (3) years; or provide evidence of no TB disease per negative result of interferon-gamma release assay blood test (T-Spot or Quantiferon Gold) within twelve (12) months of student activity at facility; (b) a completed series of Hepatitis-B vaccine, having begun the series, or informed refusal of the vaccine; and (c) any other appropriate immunizations requested by Facility.

Documentation for legally-required testing requirements noted. See Addendum 3. Ensure that Students are aware of the Substance Policy. See Addendum 4. Provide the Facility with a copy of each Student's completed (1) Substance Policy Consent Form (See Addendum 4) and (2) Background Consent Form (See Addendum 5). Students: Completed Addenda 4, 5 and 6. Crestwood Medical Center Nursing Informatics USA/Faculty: Obtain written documentation from Students and staff Huntsville, Alabama prior to referring them to Facility: a negative TB skin test within the past year or, in the event of a positive TB skin test, a chest x-ray within the past three (3) years; or provide evidence of no TB disease per negative result of interferon-gamma release assay blood test (T-Spot or Quantiferon Gold) within twelve (12) months of student activity at facility; (b) a

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered completed series of Hepatitis-B vaccine, having begun the series, or informed refusal of the vaccine; and (c) any other appropriate immunizations requested by Facility.

Ensure that Students are aware of the Substance Policy. See Addendum 4. Provide the Facility with a copy of each Student's completed (1) Substance Policy Consent Form (See Addendum 4) and (2) Background Consent Form (See Addendum 5). Students: Completed Addenda 4, 5 and 6. Cross Creek Hospital Undergraduate and Graduate Nursing Austin, Texas Cullman Regional Medical Center RN, RN-BSN, MSN, DNP Cullman, Alabama Agreement only covers hospital. Renewal in process-set to expire 12/1/2018 Cumberland County Health BSN, RN-BSN, MSN, DNP Department Fayetteville, North Carolina

Cumberland County Hospital BSN, MSN, DNP, Students must complete Appendix 1 prior to beginning APRN clinicals. System, Inc. d/b/a Cape Fear Valley Health System (to include Complete hospital’s orientation found on website Cape Fear Valley Medical (www.capefearvalley.com)

Center, Behavioral Health Contact Cape Fear Valley’s Human Resources Center, Highsmith-Rainey Department to obtain a student badge.

Specialty Hospital, Hoke Clinical Affairs Contact is Nyoka Jones Healthcare, and Bladen Hospital [email protected] Fayetteville, North Carolina Cypress Creek Hospital Nursing USA/Faculty: Provide to the Facility’s Education Department the following, number of students, possible Houston, Texas dates of clinical, names and pertinent information regarding the student, objectives for clinical experience. Student: Must obtain criminal background and child abuse clearance checks prior to clinical and provide verification of those checks to Facility.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered DSHS Mental Health Division USA/Faculty: May be required to submit the following information to facility: beginning and end dates of (Western State Hospital) clinical, number of students, specific days, hours, Olympia, Washington and locations, learning objectives, performance expectations for students, deadlines and format of the progress report and/or evaluation forms. Must provide curriculum and the professional and academic credentials of its faculty for the students. Student: Must have yearly PPD TB testing or follow- up if student is ppd-positive. Must have background record from the Washington State Patrol and provide to facility. DSHS Rusk State Hospital Student: Must obtain health and Rusk, Texas accident insurance policy and provide verification of coverage to facility. For each student participating in the program, University shall require the student to submit fingerprints through the Fingerprint Applicant Services of Texas (FAST) form for a Texas/FBI criminal history check and obtain a pre-assignment criminal history, nurse aide registry and employee misconduct registry clearance that ensures compliance with 25 Tex. Admin. Code §414.504(d), which prohibits a DSHS facility from allowing an individual to be employed by, assigned volunteer status at, or serve as a professional clinical intern at the facility who has been listed as revoked in the Nurse Aide Registry (maintained by the Department of Aging and Disability Services), listed as unemployable in the Employee Misconduct Registry (maintained by the Department of Aging and Disability Services), or convicted of any offense identified on Attachment A, which is incorporated by reference and made a part of this Contract. All costs associated with the criminal history and registry clearances shall be paid by the University or by the student. This information shall be used to determine if an offense may be a prohibition or contraindication to students being eligible to participate in the clinical rotation at the Facility. Students who have not passed the criminal background check will not be permitted on Facility premises.

Danita’s Children Nursing Nashville, Tennessee Davis Regional Medical Center MSN and DNP See Addendum 1 for Duties to be provided by Advanced Practice Students. Statesville, North Carolina Complete Addendum 4-6.

A negative TB skin test within the past year or, in the event of a positive TB skin test, a chest x-ray within the past three (3) years; OR provide evidence of no TB disease per negative result of interferon-gamma release assay blood test (T-Spot or Quantiferon

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Gold) within twelve (12) months of student activity at facility; A completed series of Hepatitis-B vaccine, having begun the series, or informed refusal of the vaccine; DaVita Medical Management, LLC Graduate Nursing USA/Faculty: provide Agency with records of each Student’s physical examinations, immunization (covers all sites) statuses, and other medical tests as requested by Colorado Springs, Colorado Agency and consistent with Agency’s policies.

Student: Complete Exhibit A&B. Note: Please read carefully. Daughters of Charity Services of Undergraduate and Graduate Nursing New Orleans New Orleans, Louisiana Dayton VA Medical Center MSN, DNP MSN and DNP Programs. Dayton, Ohio DCH Hospital Authority (includes BSN, RN-BSN, MSN, USA/Faculty: Annual Report of Influenza Fayette Medical Center, Northport Medical DNP Immunization Rate to be completed by Clinical Affairs. USA must submit request four weeks prior to Center) clinical start date. Tuscaloosa, Alabama Renewal in process-set to expire Student will need to sign the Acknowledgement Form of the Policies and Procedures (available from 10/4/2018 Facility). If student is placed in Facility for more than 12 months they will need to provide proof of a negative TB skin test annually. Deaconess Hospital, Inc. Nursing See Exhibit A for Program Requirements Contact: Belle McCool - Evansville, Indiana [email protected] 812-450-2116 USA/Faculty: Provide names and phone number of student’s faculty. Provide description of the expected clinical educational experience including activities and objectives for the program, roles for the clinical experience and clinical department assignments. Provide a skills checklist or formal validation of the Students’ competency in performing the skills required in the clinical education experience upon request. Student: Must participate in Hospital orientation. Dekalb Medical Center RN-BSN, MSN, Student: Must complete Hospital orientation. Decatur, Georgia DNP, NP

Denver Health and Hospital MSN, DNP Term for each student must be agreed upon at least (1) one month prior to the start of clinicals in writing. Authority Faculty must send facility the name of each Student Denver, Colorado enrolled in clinicals, along with the Attestation Letter (available from the contract office) 30 days prior to clinicals (to provide evidence of: Immune status for Measles, Mumps, Rubella, and Varicella for Measles, Mumps, Rubella must provide evidence of two doses of MMR vaccine if born after 1957, or positive measles, mumps, rubella titers) and has completed immunization for Hepatitis B or letter of declination on file prior to the beginning of clinicals. Students that work with 12 month olds or younger shall be required to furnish regarding immunizations and booster protection against pertussis. Student must have had a PPD test in the past year. If student shows a past history of positive TB skin test, must show evidence

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered of an annual assessment to rule out active TB. Students must have received annual influenza vaccine or declination on file. Seasonal influenza vaccination is required of all Students rotating at facility between October and March of each year. Students must obtain Workers Compensation Insurance through facility at the Student’s expense. Students must carry health insurance coverage under an accident and sickness health insurance plan. Students must be 18 years or older. Desert Regional Medical Center, RN-BSN, MSN, USA/Faculty: See Exhibit C. DNP Agency contact: Christine Horton Inc. [email protected] Palm Springs, California 760-323-6133

Student: Complete Exhibit A&B. Detroit Medical Center Nursing Clinical Affairs-Complete Exhibit C-Attestation.

Detroit, Michigan Students: Complete Exhibits A&B. Students show evidence to include without limitation the completion of a two step tuberculin skin test (within the last six months) or evidence that each Program Participant is free of symptoms of pulmonary disease if the skin test is positive, a chest x-ray following a positive TB test result, negative drug screening, physical examination, proof of rubella, and rubeola immunity by positive antibody titers or 2 doses of MMR, and evidence of completion of the series of three hepatitis B vaccinations (if required by applicable law or Hospital policy). Must view videotape regarding Hospital’s patient information privacy policies.

Diagnostic Clinic of Longview Nurse Practitioner Student: Must completed addenda 4-6. A negative TB skin test within the past year or, in Longview, Texas the event of a positive TB skin test, a chest x-ray within the past three (3) years; OR provide evidence of no TB disease per negative result of interferon- gamma release assay blood test (T-Spot or Quantiferon Gold) within twelve (12) months of student activity at facility; (b) a completed series of Hepatitis-B vaccine, having begun the series, or informed refusal of the vaccine; and (c) any other appropriate immunizations requested by Facility. Dickinson County Healthcare Undergraduate and Graduate Nursing System Iron Mountain, Michigan Dignity Health (St. Joseph’s Undergraduate and USA/Faculty: Please see all exhibits A-E. (Exhibit D Graduate Nursing is the Ethical and Religious Directives of Agency) Hospital and Medical Center), St. At least two weeks prior to clinical experience Joseph’s Westgate Medical Center, provide to Hospital information from Exhibit B. USA Chandler Regional Medical Center Faculty do not have to sign Exhibit C as they are not on-site of facility. and Mercy Gilbert Medical Center) Student: Must reimburse Hospital for any emergency Phoenix, Arizona health care of first aid provided by Hospital. Must Renewal in process-set to expire complete Exhibit C. on 9/2/2018

Dignity Health (covers, Marian Regional Nursing Contact USA Clinical Affairs regarding Background Medical Center-Santa Maria and Arroyo Grande Screening Process. Campuses, French Hospital Medical Center, St.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered John’s Regional Medical Center, St. John’s Pleasant Valley Hospital) Part 3-6 to be completed. Santa Maria, California DLP Wilson Medical Center, LLC, Undergraduate and Graduate Nursing DLP Wilmed Nursing and Students Rehabilitation Center, LLC Wilson, North Carolina DLP Wilson Physician Practices Undergraduate and DLP Wilson Physician Practices Graduate Nursing Wilson, North Carolina Students Wilson, North Carolina Doctors Hospital of Augusta Nursing Students must complete Exhibit s A & B. Faculty must sign Attestation Exhibit C for satisfactory Augusta, Georgia Background Investigation and Drug & Alcohol Report. Please see list of required Background Check and Drug Screen inclusions. Please see Affiliation Process from the agency’s Education Department. Doctors Medical Center of Modesto, BSN, RN-BSN, RN- Inc. MSN and NP Modesto, California Dominion Hospital USA/Faculty: Provide adequate Falls Church, Virginia documentation attesting to competency of each instructor, as appropriate.

Student: Must sign a Statement of Responsibility (Exhibit A), and a Statement of Confidentiality and Security (Exhibit B). May be requested to obtain Professional Liability Insurance above the amounts that USA provides. Must pass a medical examination at least one year prior to clinicals, or otherwise required by Virginia law. Annual flu vaccination (proof of flu vaccination October 1st-March 31st) as required by Hospital policy. Hospital may, at its discretion, conduct an alcohol test on Students. Driscoll Children’s Hospital MSN, DNP Students must complete Exhibits A & B prior to beginning clinicals. CON must complete Exhibit C on Corpus Christi, Texas behalf of student. Effective Flu Season 2011, the Influenza Vaccine is MANDATORY for all program participants (instructors and students). Exhibit C must be completed prior to beginning clinicals.

Duke University Affiliated CANCELLED Student will not be permitted on-site without 4/30/2018 documentation verifying Criminal Background Check Physicians, Inc. EFFECTIVE MAY 11, and Immunization status & signed Confidentiality Durham, North Carolina 2018. Statement on file. Student will need to complete DO NOT APPROACH FOR A TWO Compliance and Safety Training and have current CPR certificate. Faculty should contact Contract PAGE AGREEMENT person at CON regarding student’s paperwork. Duke University Health System, Inc. CANCELLED Student will not be permitted on-site without 4/30/2018 documentation verifying Criminal Background Check Durham, North Carolina EFFECTIVE MAY 11, and Immunization status & signed Confidentiality 2018. Statement on file. Student will need to complete DO NOT APPROACH FOR A TWO Compliance and Safety Training and have current CPR certificate. Faculty should contact Contract PAGE AGREEMENT person at CON regarding student’s paperwork.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Duncan Regional Hospital Graduate MSN and Agency contact: Vera Budlong- Education DNP students Supervisor Duncan, Oklahoma [email protected]

USA/Faculty: Provide student name and name of their clinical instructor prior to the beginning of the clinical experience. Provide immunization record, current CPR certification.

Durham VA Medical Center Durham, North Carolina DW McMillan Hospital (covers Undergraduate and Students will be required to complete an orientation Graduate Nursing to the Hospital. Either in person or via an orientation Flomaton Medical Center and packet. Must have proof of medical insurance. Castleberry Clinic) See Education Checklist for additional requirements. Brewton, Alabama Contact: Debbie [email protected].

Dyersburg Regional Medical Center BSN, RN-BSN, USA/Faculty: Provide written documentation (purchased by West Tennessee MSN, DNP on: student’s immunizations, to include TB skin test within past year or if positive test, chest x- Healthcare) ray within the past 3 years, completed series of Dyersburg, Tennessee Hepatitis-B vaccine, or informed refusal of the vaccine. Legal required testing as written in Addendum 3, Provide facility with each Student’s completed: Substance Policy Consent Form (Addendum 4). Background Consent Form (Addendum 5). Copy of forms must be on file at facility before student may begin clinicals.

Student: Must adhere to Substance Policy. See Addendum 4. Must have health insurance during clinicals at facility.

Agency Name Programs Agency Requirements Covered East Alabama Medical Center- BSN, RN-BSN, MSN, DNP EAMC Lanier (all affiliated entities are covered by agreement) Valley, Alabama East Central Mississippi Health Undergraduate and Graduate Nursing Care, Inc.(to include: Sebastopol Medical Programs & Dental Clinic, Walnut Grove Medical Clinic, Philadelphia Health Center, Newton Health Care) Sebastopol, Mississippi

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered East Cooper Medical Center RN-BSN, MSN, *Student and Preceptor must view videotape DNP regarding Hospital's patient information privacy Mount Pleasant, South Carolina policies and practices provided by Hospital. Verification must be sent to USA Clinical Affairs Office-Beth Collier [email protected] for recordkeeping purposes.

USA/Faculty: Complete Exhibit C-Attestation.

Student: Complete Exhibits A& B. Must secure health insurance coverage.

East Georgia Regional Medical RN-BSN, MSN, DNP USA/Faculty: Please see Addenda 1 for patient care duties for nurse practitioner students. Center Statesboro, Georgia Student: Must complete Addenda 4-6. Students must have; Health Insurance A negative TB skin test within the past year or, in the event of a positive TB skin test, a chest x-ray within the past three (3) years; OR provide evidence of no TB disease per negative result of interferon-gamma release assay blood test (T-Spot or Quantiferon Gold) within twelve (12) months of student activity at facility;

A completed series of Hepatitis-B vaccine, having begun the series, or informed refusal of the vaccine; East Jefferson General Hospital NURSING Education Contact: David Potter (East Jefferson Women’s Care is CME/GME Coordinator, EJGH covered) Phone: (504) 503-4283 Metairie, Louisiana Email: [email protected]

Faculty needs to provide roster of students, etc. *Students must submit a letter to CNO regarding goals outlined by the school and the student for the practicum and a copy of the student’s current vitae. *Graduate students must be interviewed by EJGH oversight committee members to discuss mutual goals and objectives. *Students must have preceptor selected by Director of CNKR and meet with preceptor prior to starting practicum. East Tennessee Children’s Hospital MSN, DNP USA/Faculty: Must provide training and education programs to all students on the OSHA/Blood Borne Knoxville, Tennessee Pathogens. Students: Must have a health insurance policy in effect. East Texas Medical Center-Tyler Undergraduate and Student must complete the “Request for Graduate Nursing Tyler, Texas Student Practices Advanced Practice Nurse Students Student” form. Eastar Health System Nurse Practitioner Student must complete Statement of Responsibility and Statement of Confidentiality and Security. Must Muskogee, OK have annual medical examination if required by hospital. Eastern Maine Medical Center BSN, MSN Bangor, Maine Eastern Virginia Medical School MSN, DNP Student: Must obtain/maintain ALL liability insurance coverage (Students, shall obtain and maintain at all (EVMS) Department of OB/GYN times professional liability insurance with limits Norfolk, Virginia sufficient to meet the maximum amount recoverable

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered as set forth in Virginia Code Section 8.01-581.15 as amended, or any successor statute thereto, per occurrence and three (3) times the maximum amount set forth above in the aggregate annually. If the policy is of a claims made type, such policy shall provide for a retroactive date that is no later than the December 15, 2015 and, upon termination or expiration of this agreement, coverage shall continue until the expiration of the applicable statute of limitations period for the activities undertaken by Facility and Institution hereunder, but in no circumstances for less than two (2) years). Must provide a certificate of coverage to the Facility and University, prior to the beginning of clinical experience. Must obtain and maintain health insurance coverage. Eastside Medical Center MSN and DNP USA/Faculty: Complete Exhibit C-Attestation. Snellville, Georgia Student: Complete Exhibit A & B. Must pass medical examination acceptable to Hospital at least once a year while in clinical experience at Hospital. Ector County Hospital Nursing Programs Student must have health/accident insurance. Students must have TB test and/or chest x-ray District/Medical Center Health results taken within the previous 6 months. System Drug/alcohol screening within the previous two Odessa, Texas weeks. USA must verify that each student has been cleared through the background check and drug/alcohol screening processes. Upon request student must release background check and drug/alcohol screening results to Facility. Edward Health Ventures (to include: BSN, MSN, DNP Students: Must maintain comprehensive health Hospital-Main Campus, All Edward Medical insurance. Group locations, Edward Healthcare Center and Edward Medical Group Physician Offices, Edward Neurosciences Institute and Edward Medical Group Offices) Naperville, Illinois Edward Hospital MSN, DNP Student: Must maintain comprehensive health insurance. Obtain prior written approval of the Elmhurst, Illinois Facility before publishing any material relating to the clinical experience. Edward W. Sparrow Hospital Assoc. MSN, DNP USA/Faculty: At least one month prior to clinicals provide curriculum, program description, objectives, Lansing, Michigan semester dates, student names, work schedules, name of faculty coordinators, and preceptors. Students: Must complete Exhibits A-C. Eglin Air Force Base, 96th Medical BSN, RN-BSN, Undergraduate and graduate nursing degree MSN, DNP programs– Students must sign the Trainee Group/SGSF Agreement Addendum. Faculty and/or Students Eglin AFB, Florida must contact Sherri Prejean at 850-883-8080 or [email protected] prior to beginning of clinicals for approval. El Rio Community Health Center Undergraduate and Tucson, Arizona Graduate Nursing Students Eliza Coffee Memorial and Shoals Nursing Students: Complete Exhibit A & B. Hospital Florence, Alabama Elliot Health System BSN, MSN, DNP

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Manchester, New Hampshire USA/Faculty: Must provide clinical practicum objectives to facility. (Deborah Langton - 603- 663-2715). Student must complete Confidentiality Agreement through agency. EmCare, Inc. (covers Bailey Medical Center) BSN, RN-BSN, MSN, EmCare LON not required. Agency LON DNP Clearwater, Florida required.

Contact-Mark McGrew [email protected] Emerald Coast Behavioral Hospital Undergraduate and Graduate Nursing Panama City, Florida Emergency Medicine Associates, MSN NP Only USA/Faculty: At least six (6) weeks prior to the start of any anticipated Clinical Experiences, submit a PA, PC written request to the Administrator indicating the (to be utilized in conjunction with number of Students expected to be assigned to each Clinical Experience, the length of time and dates of the Novant Prince William and each Clinical Experience, and the proposed days Novant Culpeper agency’s only) and hours of each Clinical Experience. The specific Germantown, Maryland placement of Students, including schedules and the exact number of Students, shall be mutually agreed upon by the parties. The Institution shall provide the Administrator with the name of each Student participating in a Clinical Experience at least thirty (30) days prior to the start of the Clinical Experience and shall promptly notify the Administrator of any changes. Provide documentation prior to the beginning of each Clinical Experience certifying to its knowledge that each Student meets the health requirements established by the Facility. Each Student shall have health insurance coverage and shall provide to the Administrator prior to commencement of the Clinical Experience documentation evidencing such coverage. Provide documentation of PPD or CXR within one year and evidence of inoculation for Hepatitis B or a declination signed by Student for each such Student. The Institution shall provide educational program(s) for Students regarding Occupational Health and Safety Act ("OSHA") compliance standards prior to the start of any Clinical Experiences.

Provide to the Administrator the name and telephone number of the Faculty who shall: (i) Plan, in conjunction with the Facility staff, Clinical Experiences which will fulfill the Program's educational requirements and meet the objectives mutually agreed upon by the parties; (ii) Meet with the Facility staff to evaluate the Clinical Experiences and discuss any problems which have arisen; and (iii)Notify the Facility of any changes in the Program's curriculum.

Emergency Professional Services, Nursing Inc. (Team Health for OH and MI) Knoxville, Tennessee

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Ephraim McDowell Health, Inc. (all All Nursing Programs Student: Must complete the Statement of Understanding and Confidentiality Agreement. affiliated and related entities covered by agreement) Danville, Kentucky Eskenazi Health Nursing USA/Faculty: Provide agency with an overview of the aims, objectives and activities of the clinical Indianapolis, Indiana experience annually. Maintain on file and provide to Eskenazi Health upon request, the following information for each student: Verification of a health screening and physical; Verification of a current vaccination against rubeola, rubella or recent results of the student’s immunity status plus documentation assuring the student is free from active infection of each of the above; Verification of Hepatitis B vaccination and/or signed refusal of such; Verification of current vaccination against varicella or recent result of student’s immunity status which could include titer or physician documentation of having had the disease. if the student’s clinical experience occurs during the flu season as designated by Eskenazi Health, verification the student received a flu vaccination, or evidence of a medical exemption from this requirement; current results of tuberculosis (skin and/or x-ray) tests assuring that the student is free from active infection of tuberculosis; The Institution/school shall advise its students to obtain appropriate background checks before they commence the Clinical Placement program with Eskenazi Health. Verification of a urine drug screen; Verification that School and student have not been excluded from participation in any federal or state program, including Medicare and Medicaid; Verification that faculty and students have received instruction on HIPAA compliance; Verification of appropriate licenses, certification and/or qualifications. Essentia Institute of Rural Health NNP STUDENTS USA faculty will need to reference Essentia Duluth, Minnesota and the Dual Role- Health's website at FNP/AdultGeron http://www.essentiahealth.org/for_vendors. Acute BSN-DNP html to review the Code, its updates. USA Program faculty must provide program objectives to Only agency. Evans Army Community Hospital MSN, DNP USA must send names of students, dates & hours requested 60 days prior to clinicals to agency. Fort Carson, Colorado Exodus Recovery, Inc. Undergraduate and Graduate Nursing Culver City, California

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Fairfax Falls Church Community MSN, DNP USA/Faculty: Supply the Facility with materials, including instructional criteria for evaluating student's Services Board performance. Upon request, USA will ensure each Fairfax, Virginia student placed at Facility completes a Student Profile Sheet and a post clinical evaluation for the Department of Staff Development and Training. Fairfax Medical Facilities, Inc. Undergraduate and Student must check in with HR Director, Amber Graduate Nursing Hightower-918-642-3100. Fairfax, Oklahoma Fairview Health Services (covers RN-BSN, MSN, Rotation Requests must be made through all divisions, affiliates, and sites of DNP TCCP or they will not be accepted.

Fairview, including HealthEast) Employees Only Students are recommended to have a one- Minneapolis, Minnesota time vaccination of Pertussis (t-dap). Employees Only Faith Regional Health Services Nursing Complete Exhibit A-Attestation Norfolk, Nebraska

Student must contact Faith Regional University 402-644-7347 to find a preceptor.

Preceptor requirements per agreement: Preceptors will have an established practice for at least 12 months in a geographic area where student/preceptor interaction will occur and preceptors shall further be qualified as follows: -for BSN students will have completed an approved Baccalaureate of Science in Nursing education program, be licensed as a Registered Nurse in Nebraska, have at least 24 months experience in the practice of professional nursing, and expertise in the area of practice related to the responsibilities of the appointed position. -for nurse practitioner students will be physicians and nurse practitioners who have graduated from an approved/accredited program and who are appropriately licensed and certified in their specialty. -for clinical nursing specialist students will be advanced practice nurses with a minimum of a Master’s degree, physicians, and/or public and community health leaders. -Other preceptors must have the equivalent or higher degree that the student is pursing in his/her education.

Family Healthcare BSN, RN-BSN, St. George, Utah MSN, DNP Family Health Care Center MSN, DNP Faculty, any correspondence with preceptors must be copied to Mr. Dennis Kruse, CFO-401 Holly Hills Saint Louis, Missouri Avenue, St. Louis, MO 63111-2410 Feather River Hospital Undergraduate and Graduate Nursing Paradise, California Federal Bureau of Prisons Nursing Students USA/Faculty: Prior to assignment of students, furnish to Agency liaison the following: Butner, North Carolina a list of students and faculty to participate in the clinical

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered experience at the Agency Institution and the clinical areas and dates of assignments requested and certain personal information needed to facilitate a criminal background clearance by Agency for the participating students at least 14 days/2 weeks before beginning of assignment, a signed “Student Non-Disclosure Agreement,” as Attachment A, for each listed student. A statement that includes the following: Listed students that are in compliance with Agency employee health requirements, including the absence of tuberculosis; and the listed students and faculty have received all immunizations, tests, and vaccinations required under federal and state law; and the listed students and faculty maintain appropriate professional liability insurance. Upon request, provide proof thereof, e.g. a copy of the policy or the paid premium; and listed students and faculty maintain appropriate health insurance, as they shall be responsible for any medical treatment they may need for any injury or illness that may occur while at the Agency Institution. Student: Complete Attachment A. Must maintain health insurance. Flaget Memorial Hospital Nursing Program Student: Must complete Exhibits A&B Must undergo a physical examination to include the Bardstown, Kentucky following immunizations and tests as per CDC guidelines: (i) a complete Hepatitis B vaccination series; (ii) annual TB screening (including chest x-ray, if applicable); (iii) MMR vaccination(s) or positive titer(s); (iv) varicella vaccinations or a varicella titer. Flagler Hospital, Inc. Graduate Nursing USA/Faculty: Providing to Flagler an accurate list at all Programs times the names of those students participating in St. Augustine, Florida clinical experience.

Students must have physical examination, certain immunizations or other infection prevention or control policies or practices prior to and during the educational experience(s) which may be required by Flagler’s infection prevention or control programs, policies or initiatives, a tuberculin skin test prior to clinical experience, and a chest x-ray if indicated. Fletcher Allen Health Care MSN,DNP (University of Vermont Medical Center) Burlington, Vermont Florida Department of Health- Undergraduate or Student must complete Attachment A-Confidentiality Graduate Agreement and submit to Balinda Welcome, Education Duval County and Training [email protected] Jacksonville, Florida 904-253-2278 prior to clinicals. Florida Department of Health- Nursing Students are background screened and meet the Level 2 screening requirements of section 435.04, Florida Escambia County Statutes prior to students beginning their clinical Pensacola, Florida experience at the CLINIC. Florida Department of Health BSN, RN-BSN, Students are background screened and meet the Level MSN, DNP 2 screening requirements of section 435.04, Florida Includes: Holmes County Health Statutes prior to students beginning their clinical Dept. experience at the CLINIC. Bonifay, Florida Florida Department of Health Lee RN-BSN, MSN, DNP Agency contact: Yvonne McConnell-239-332-9569- [email protected]. County

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Fort Myers, Florida Student must provide a background check that includes a fingerprint FBE and FDLE screening that has been done within the last 5 years, prior to beginning clinical. Student must provide the agency with verification they have met the requirements for vaccinations and TB testing pursuant to the DOH policy. Florida Department of Health-Levy BSN, RN-BSN, USA must submit a schedule naming the students RN-MSN to attend and the planned attendance dates County Health Department (Barbara Locke-352-486-5300 ext. 232- Bronson, Florida [email protected]). Florida Department of Health Student must provide a background check that includes a fingerprint FBE and FDLE screening Seminole County that has been done within the last 5 years, prior to Sanford, Florida beginning clinicals. Renewal in process-set to expire Student must provide the agency with verification 12/31/2018 they have met the requirements for vaccinations and TB testing pursuant to the DOH policy. Florida Department of Health Nursing USA/Faculty: Submit to Agency a schedule indicating the number and names of student(s) who will be Volusia County participating in a clinical experience, along with the Daytona Beach, Florida faculty who will be indirectly supervising students. Florida Emergency Physicians Graduate Nursing *Agency may provide for physician, nurse Kang & Associates, M.D. Students practitioner, and/or physician’s assistant staffing at certain hospitals. Knoxville, Tennessee (Corporate) Florida Hospital Fish Memorial USA/Faculty: Changes in staff or curriculum affecting either party shall be subject to immediate notification of (SW Volusia Healthcare Corp.) the parties. Orange City, Florida Student: Each student shall attend all activities involving the department assigned. Must have written character references on file with USA. Provide facility with all forms (if any) regarding practicum experience and instruction for completion of forms. Florida Hospital Heartland Medical MSN and DNP USA/Faculty: Provide course outlines to Hospital to include objectives, goals and classes for each course Center and Florida Hospital providing education experiences. Wauchula ( to include campuses at Provide a letter of good standing to Hospital indicating Highlands County, Hardee County that each Student has had a physical examination and is current on all immunizations prior to his/her and Sebring) participation in the Rotations. The physical Sebring, Florida examination shall include general physical exam, utilizing history (mobility, motor skills, hearing, visual and tactile abilities) and immunization assessment and any other exam that Hospital may reasonably require. Students and Faculty must have current immunizations including: Varicella, if titer is negative for Varicella, the Student must receive Varicella vaccine, Hepatitis B or signed waiver if refused, MMR, Tetanus, PPD current within one year. If Student has positive PPD results, Academic Institution will provide confirmation that Student has a negative chest x-ray. Academic Institution will notify Hospital of any positive PPD results. A Student who may be exposed to a patient with known or suspected TB must be fitted for a respirator. Influenza vaccine for current influenza season (October 1 through March 31.Academic Institution will maintain required immunization records in support of the letter of good standing.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Provide a letter of good standing indicating that a criminal background check has been conducted on all Students 18 years of age or older and all Faculty, prior to commencement of a Rotation. The criminal background check must include all cities, counties, and states in which the Student or Faculty has resided in and in which the Student or Faculty has worked at any time during the past ten (10) years. Attached hereto as Exhibit C is Hospital’s “Student Disqualification Guidelines — Criminal Background” to be used by Academic Institution in connection with the background checks. Academic Institution will not send any Student who would be disqualified pursuant to Florida Law and the Hospital’s facility policy to participate in a Rotation. Hospital retains the ultimate right to determine if a Student is qualified.

Provide a letter of good standing indicating that a ten panel Drug Screen has been conducted on all Students prior to the commencement of a Rotation. The ten panel drug test shall consist of Cannabinoids, Methaqualone, Barbiturates, Benzodiazepines, Methadone, Propoxyphene, Amphetamines, Cocaine, Opiates and Phencyclidine.

Present Students for Rotations who have adequate preclinical instruction and who, in the discretion of the Faculty, have adequately fulfilled the preclinical requirements for the Rotation.

Provide Hospital in writing, the names of the Students assigned by Academic Institution to participate in the Rotation prior to the beginning of the Rotation. Florida Hospital Medical Group, BSN, RN-BSN, MSN, See Exhibit C-Student Disqualification DNP Inc. Guidelines-Criminal Background.

Maitland, Florida Must provide a letter of good standing to the agency, indicating student name, student has had a physical examination and is current on all immunizations, criminal background check, five panel drug screen has been conducted to consist of Amphetamines, Marijuana, Cocaine, Opiates and Phencyclidine prior to the clinical experience. Student must be fitted for a respirator. Florida Hospital Memorial Medical Nursing USA/Faculty: Provide a copy of the objectives for the experience to Nancy Grande RN, BSN Center also covers Florida CME and Student Coordinator- Hospital-Flagler [email protected] Daytona, Florida Prior to School assigning a student to engage in practicum experiences at the Hospital, the School shall undertake (personally or through a third party) a Florida Department of Law Enforcement Level 2 criminal background check on the student as provided under F.S. 435.04.

Student: Provide evidence that student has met all requirements of current CPR certification, flu vaccination, hepatitis B vaccination, a history of chicken pox disease or proof of immunity via tier or vaccination, rubella and rubeola immunity by

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered documented immunization or titer, Respiratory Fit Testing for N95 Respirator if assignment includes caring for patients with active TB, annual TB surveillance, and training on OSHA requirements for prevention of transmission of blood borne pathogens, within the last 12 months. Require a five panel Drug Screen on all students prior to the commencement of their initial clinical rotation, to be valid through students rotation, unless a student takes a leave of absence from School for more than one year, in which case a Drug Screen shall be repeated. The five panel Drug Screen shall test for Amphetamines, Marijuana, Cocaine, Opiates and Phencyclidine. Complete Acknowledgement for confidential Information & Protected Health Information Access form upon orientation to the hospital.

Florida Hospital North Pinellas Nursing USA/Faculty: Please complete the Student/Preceptor Letter (fillable) and submit to Clinical Affairs for Tarpon Springs, Florida signature, then return to Agency. Please provide a copy of the objectives for the education experience and any required forms regarding the practicum and instructions for completion of these forms.

Student: Must complete the Hospital's Acknowledgement for Confidential Information and Protected Health Information Access form upon orientation to the Hospital. Must have a Florida Department of Law Enforcement Level 2 criminal background check completed and provide results to University and Hospital. Florida Hospital Tampa NURSING Students must assume responsibility for and Tampa, Florida maintain health insurance. Provide agency with documentation of their criminal background check and immunizations. Florida State Hospital Undergraduate and Graduate Nursing Chattahoochee, Florida Students Flowood Merit River Oaks Medical Nursing USA/Faculty: See Addenda 1-2 for duties that can/cannot be performed. Group (sites covered: Merit Health Ridgeland, Head and Neck Surgical Students: Must complete Addenda 4-6. Must have Group, Transformations at River Oaks, passed a background check within 12 months CarePlus at the Reservoir, ROH Center for preceding Student’s provision of Patient Care Infectious Disease, CarePlus Madison Services. Must have passed a substance test in the 12 Family Medical Clinic, Merit Health Walk-In months preceding placement at the facility. Clinic) Student must have health insurance while in clinical at Facility. Flowood, Mississippi a negative TB skin test within the past year or, in the event of a positive TB skin test, a chest x-ray within the past three (3) years; OR provide evidence of no TB disease per negative result of interferon-gamma release assay blood test (T-Spot or Quantiferon Gold) within twelve (12) months of student activity at facility; (b) a completed series of Hepatitis-B vaccine, having begun the series, or informed refusal of the vaccine; and (c) any other appropriate immunizations requested by Facility. Floyd Healthcare Management RN-BSN, MSN, Rome, Georgia DNP

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Floyd Memorial Hospital and Health Services New Albany, Indiana Forrest County General Hospital BSN, MSN, DNP Please see Exhibit C for any additional requirements. Hattiesburg, Mississippi

Fort Belvoir Community Hospital MSN, DNP Students: Must complete Trainee Agreement. Students will be required to have an ACCESS NATIONAL Fort Belvoir, Virginia AGENCY CHECK and INQUIRIES (ANACI) investigation with an IT-2 Level Designation as they will have PHI and network access. This includes but is not limited to a full background check including fingerprinting. Student who will provide health care to patients under the age of 18 on a regular basis will submit to a state criminal history repository (SCHR) check as indicated by the Department of Defense Instruction 1402.5. Fort Smith HMA, LLC d/b/a Sparks MSN, DNP Nursing students wishing to participate under this Agreement must contact Theresa Phillips in Human Health System Resources 479-441-5458 to set up an appointment to Fort Smith, Arkansas begin the screening and orientation process.

Fort Walton Beach Medical Center Student must take Compliance test from agency prior to beginning clinical rotation. Also exhibits must be Ft. Walton Beach, Florida completed.– Agency contact: Josie Sabat- [email protected]. Fox Army Health Center MSN, DNP Redstone Arsenal, Alabama Franciscan Health System (to USA/Faculty: Require each student to complete include: St. Francis Hospital, St. training and education (OSHA approved, where Clare Hospital, St. Anthony applicable) on the following prior to clinicals: universal Hospital, St. Elizabeth Hospital, precautions and infection control; body mechanics; fire safety and disaster safety; HIPAA; any other training Highline Medical Center, Harrison identified by Hospital. Medical Center and the Regional Student: Must have physical examination to include the Hospital for Respiratory and following immunizations and tester as per CDC Complex Care) guidelines: complete Hepatitis B vaccination series; Tacoma, Washington annual TB screening (including chest x-ray, if applicable); MMR vaccination or positive titer; varicella vaccination or varicella titer. Must complete Attachment A-Student Participation Agreement and Waiver and Attachment B - Consent for Student to Submit and /or Alcohol Testing Authorization for Release. Franciscan Medical Group RN-BSN, MSN, USA/Faculty: Please review the CHI Standards of DNP Conduct - Tacoma, Washington http://www.catholichealthinitiatives.org/corporate- responsibility. May be required to complete a Clinical Site Information Form to indicate information regarding the qualifications and responsibilities of the facility coordinator. Facility will provide.

Student: Must complete attachments A&B. Must have completed training and education (OSHA approved, where applicable) for universal precautions and infection control, body

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered mechanics, fire safety and disaster safety, HIPAA prior to clinical experience. Franciscan Pace, Inc. MSN, DNP USA/Faculty: Prepare student assignments and rotation plans for each student and coordination of Baton Rouge, Louisiana same with facility. Student: Must complete and sign Attachment 1 Student Agreement, Attachment 2 Statement of Responsibility, and Attachment 3 Statement of Confidentiality prior to beginning clinicals. Must have had a Tuberculin Skin Test within the past 12 months. Frankfort Regional Medical Center NP Nurse Practitioner Students Frankfort, Kentucky Student: Must sign a Statement of Responsibility (Exhibit A), and a Statement of Confidentiality (Exhibit B). Provide proof of Influenza vaccination during Flu Season, Oct. 1 - March 31, (or dates defined by CDC, or a signed Declination Form.

Franklin Primary Health Center, Undergraduate and Graduate Nursing Inc. Students Mobile, Alabama Freeman Health System MSN, DNP USA must provide a roster of student’s names and clinical rotation schedule to agency. Students Joplin, Missouri must have a Missouri Background Check to include the Missouri Employee Disqualifications List and to comply with the requirements and provisions of the Revised Statutes of Missouri. Fresenius Medical Care (many RN-BSN and MSN USA please see ALL Exhibits A-F. Exhibit A-Locations (many). Exhibits B-F Onboarding locations) Requirements. Downers Grove, IL Students will be required to undergo all standard pre- engagement screening in accordance with the Pre- Screening Requirements. Pre-Screening Requirements (as referenced by the previous subsection): (i). Multi-County Background Check Requirements: •OIG/GSA Exclusion – now FACIS – includes alias search (Level 3) •Credential Verification if applicable •Education Verification if applicable •Background checks (last seven (7) years) •Global Sanction (FBI List) •County Felony Including Misdemeanor •National Criminal File •Social Security Verification •National Sex Offender Registry •Any other state-specific background checks or verifications required by applicable state law

(ii). Ten (10) Drug Panel Test: •Cocaine •Opiates •Amphetamines •Barbiturates •Methaqualone •Methadone •Benzodiazepines •Phencyclidine •Propoxyphene •Marijuana

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Fresno Community Hospital & APRN USA/Faculty: Clinical experience dates, names of students, student’s bio info, objectives, and summary Medical Center (to include: of academic components of the curriculum completed Community Regional Medical by student should be provided to the Agency at least Center, Clovis Community Medical 30 days in advance. Contact: Joeal Venkatesan- [email protected]. Center, Fresno Heart and Surgical Hospital) Student: Must have Attachment A and Exhibit A completed. Froedtert Health Inc. Nurse Practitioner Contact the USA Clinical Placement Coordinator at Students [email protected] Milwaukee, Wisconsin

Agency Name Programs Agency Requirements Covered Gadsden Regional Medical Center, Nursing and Nurse USA Faculty please see Addena 1-3. Practitioner Students must complete Addendum 4-Substance LLC Policy Consent Form and Addendum 5- Gadsden, Alabama Background Consent Form. Gadsden Regional Physician Nursing and Nurse USA Faculty please see Addena 1-3. Practitioner Students must complete Addendum 4-Substance Group Practice, LLC Policy Consent Form and Addendum 5- Gadsden, Alabama Background Consent Form. Gadsden Regional Primary Care, Nursing and Nurse USA Faculty please see Addena 1-3. Practitioner LLC Students must complete Addendum 4-6 Gadsden, Alabama Garden Park Medical Center Nursing Student must complete Exhibit A and B. Student: Must have Tuberculin skin test within the Gulfport, Mississippi past 12 months or documentation as a previous positive reactor; and Proof of Rubella and Rubeola immunity by positive antibody titers or 2 doses of MMR; and Varicella immunity, by positive history of chickenpox or proof of Varicella immunization; and Proof of Hepatitis B immunization or declination of vaccine, if patient contact is anticipated. Proof of Influenza vaccination during the Flu season, October 1 to March 31, (or dates defined by CDC), or a signed Declination Form. Evidence of a Negative drug and alcohol screen. Background check shall include, at a minimum, the following: Social Security Number Verification; Criminal Search (7 years or up to 5 criminal searches); Employment Verification to include reason for separation and eligibility for re-employment for each employer for 7 years (not required for students younger than 21 years of age); Violent Sexual Offender and Predator Registry Search; HHS/OIG List of Excluded Individuals/Entities; GSA List of Parties Excluded from Federal Programs;

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Education verification (Highest Degree Received) U.S. Treasury, Office of Foreign Assets Control (OFAC), List of Specially Designated Nationals (SDN); Applicable State Exclusion List, if one. The background check for Program Participants who are licensed or certified caregivers shall include the above, and in addition, shall include the following:

Education verification (highest level); Professional License Verification; Certification & Designations Check; Professional Disciplinary Action Search; Department of Motor Vehicle Driving History, based on responsibilities; Consumer Credit Report, based on responsibilities.

A drug and alcohol test.

To ensure the accuracy and fairness of the testing program, all collection and testing will be conducted pursuant to guidelines established by the Medical Review Officers of the testing Hospital and, if applicable, in accordance with Substance Abuse and Mental Health Services Administration (SAMHSA) guidelines; a confirmatory test; the opportunity for a split sample; review by an MRO, including the opportunity for employees or students who test positive to provide a legitimate medical explanation, such as a physician's prescription, for the positive result; and a documented chain of custody.

Substances tested prior to placement at Hospital must at a minimum include amphetamines, barbiturates, benzodiazepines, opiates, marijuana, methadone, and cocaine.

Student will be required to undergo drug and alcohol testing upon reasonable suspicion that the Student has violated the policy, or after any “on-the-job” accident, which involves injury requiring medical treatment or evaluation of the Student or another person, or property damage. Reasonable suspicion and reportable accident testing will include amphetamines, barbiturates, benzodiazepines, carisoprodol, opiates, fentanyl analogues, methadone, meperidine, marijuana, and cocaine.

Garden Park Physicians Group, Nurse Practitioner USA/Faculty: Complete Exhibit C-Attestation. Student: Complete Exhibits A&B, along with Inc. Addendum A. Gulfport, Mississippi Renewal in process-set to expire 7/31/2018

CaroMont Health All Nursing Programs Prior to the beginning of the clinical experience, Gastonia, North Carolina student must obtain and maintain their own general liability insurance in the amounts of $1million/$3million. A certificate of said insurance must be provided to the hospital at

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Counsel for Contracts Management Department of Legal Affairs CaroMont Health, Inc. P.O. Box 1747 Gastonia, NC 28053-1747 and to USA’s Clinical Affairs Department (Beth [email protected]) Student must have annual tuberculin skin test. Geisinger Health System MSN, DNP Facility may request an Implementation Letter for an affiliated site. Please submit to Clinical Affairs for Danville, Pennsylvania completion.

USA/Faculty: See Exhibit A-Teacher/Learner Expectations. Request from Agency (Barbara Kallbach - [email protected] 570 271 6114 option 0) and complete Implementation Letter per each student. Students: Must maintain health insurance and provide proof of health insurance to USA. May be required to undergo a drug test or similar screening test pursuant to the agency's policies and practices, cost of such screening will be paid by the student. Genesis Health System MSN and DNP USA/Faculty: Must complete the attestation. Faculty and Students please see Exhibit B. Davenport, Iowa Renewal in process-set to expire 10/31/2018 Genesis Healthcare System RN-BSN, MSN, and USA/Faculty: Provide names, dates, and hours of DNP students and their assignments to Hospital at least 30 Zanesville, Ohio days in advance. Contact: Kim Smith - [email protected]. Student: Complete forms which may be requested by the Hospital. Complete the Hospital required orientation prior to the beginning of clinicals. Genesis PrimeCare RN-BSN, MSN, Marshall, Texas DNP Genesis River City Center Nurse Practitioner Student must have medical and health insurance coverage during their assignment to Agency. Student Decatur, Alabama will be skin tested for tuberculosis with the PPD test per state requirement and provide written evidence thereof to Facility upon request. Documentation of any required immunization(s) or titers as follows: a) Measles, Mumps, Rubella (MMR); b) Tetanus/Diphtheria booster; c) Chickenpox; d) Rubeola (2 MMRs); e) diphtheria; f) tetanus; and g) annual flu vaccination, unless otherwise required by state guidelines will be produced in writing upon request. Gentiva Hospice MSN, DNP Student: Must have background check that is in accordance with any and all applicable state and Columbus, Georgia federal law Caregiver Background Check Law on each on-site Instructor (preceptor) and Student. Must have OSHA training for universal precautions, blood borne pathogens and tuberculosis control. Must complete the Student Participation Agreement and the Patient Permission For Student Externship forms. George E. Wahlen Department of BSN, MSN, DNP Faculty must complete the facility’s Request for Placement form and email to Veterans Affairs Medical Center [email protected] at least 30 days prior to Salt Lake City, Utah beginning of clinical date.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Georgia Regional Hospital at USA/Faculty: Facility must approve of clinical at least one month prior. Provide upon request, student Atlanta records as will adequately disclose prior education Atlanta, Georgia and related experience. Facility contact: Nicole Wells [email protected] 404-212-4752.

Student: Facility will provide orientation to students. Student to follow CDC Standard Blood borne Pathogens guidelines and OSHA Respiratory Protection Standard (Facility will provide student with education regarding blood borne pathogens appropriate to students training at facility. Must sign a confidentiality/HIPPA agreement. Must obtain and maintain health insurance and provide proof of said insurance to facility upon request. Student must have health examination at time of clinicals to determine they are free of any infectious or contagious diseases. Student must sign Consent for Release of Information form (attached) and submit to facility. George Regional Health Systems BSN, RN-BSN, MSN, DNP Lucedale, Mississippi George Washington University Nursing Contact: Billy Mullins, DNP, RN, NE-BC Hospital [email protected] Washington, D.C. EDUCATION COORDINATOR

Provide to Agency the number of students, dates of assignment, and objectives for clinical experience.

Georgia Southern University Statesboro, Georgia Global Livingston Institute Undergraduate and Graduate Nursing Denver, Colorado Gottlieb Memorial Hospital Nurse Practitioner Student: Students Must have color blindness testing prior to clinicals. Melrose Park, Illinois Student must receive a passing score of 80% on all Agency testing.

Complete Exhibit A. Complete the Confidentiality and Network Access Agreement. Grace Pediatrics Undergraduate and Graduate Students Pleasant View, Tennessee Grady Health System BSN, RN-BSN, MSN, USA Faculty - To Schedule Clinical Experience, DNP please contact Clinical Affairs-ACEMAPP must be Atlanta, Georgia utilized. USA/Faculty and Students: Please see Exhibits B-E, for review and completion. Students notify faculty prior to starting clinicals. Please see Clinical Orientation Instructions. Grandview Medical Center MSN, DNP The student may be required to complete an orientation program with the facility. Also, the agency Dayton, Ohio may require a further background check that is in accordance with the Ohio Bureau of Criminal Identification and Investigation procedures. Grandview Medical Center Nursing and Nurse USA/Faculty: See Addenda 1 & 2 for Patient Care Practitioner Duties provided. Birmingham, Alabama Students: Must complete Addenda 4, 5 and 7.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Renewal in process-set to expire 12/31/2018 Grandview Medical Group (Affinity Nurse Practitioner USA/Faculty: Please see Addenda 1-3. Cardiovascular Specialists) Student: Complete Addenda 4-6. Birmingham, Alabama Grandview Medical Group (Affinity Nurse Practitioner USA/Faculty: See Addenda 1 & 2 for Patient Care Duties provided. Physician Services) Students: Must complete Addenda 3, 4 and 7. Birmingham, Alabama Renewal in process-set to expire 12/31/2018 The Health Care Authority of the RN-BSN, MSN, Students: Complete Addenda 4 & 5. Must have health insurance during clinical experience at Facility. City of Greenville-LV Stabler DNP Hospital (covers the Stabler Clinic) Greenville, Alabama Renewal in process-set to expire on 9/30/2018

Greenville Health System Graduate Nursing Each experience needs to be approved by GHS- Students must contact Pamela Edwards- Greenville, South Carolina [email protected] to begin the process of a CEA- Clinical Experience Agreement. This is for each student individually. Once approved GHS will notify There is not an affiliation Beth Collier and she will email the student’s USA agreement with GHS. So an LON Faculty. will not be needed. See explanation. Guadalupe Regional Medical Nursing Programs For Onboarding requirements please contact Center the Clinical Placement Coordinator at [email protected] Sequin, Texas Gulf Coast Regional Medical Nursing Programs USA/Faculty: Complete Exhibit C-Attestation. Student: Complete Exhibits A&B. Center Student must have Tuberculin skin test performed Panama City, Florida within the past 12 months or documentation as a previous positive reactor. Gundersen Health System Nursing Programs See Exhibit A for Facility Site List

LaCrosse, Wisconsin Students must have a Caregiver Background Check in accordance with the Wisconsin Statutes. Results of the background check must be completed within 60 days of when the student begins clinical experience. Gwinnett Hospital System, Inc. – Preceptor Dr. Phillip Cannon only. Lawrenceville and Duluth, Georgia Please see website for placement information: www.gwinnettmedicalcenter.org.

Gwinnett Hospital System, Inc. NP NP students only – preceptor Dr. Leslie Leigh; Students must review Exhibit “A” Permitted Activities Lawrenceville and Duluth, Georgia of the Student Student orientation materials are now on our website: http://www.gwinnettmedicalcenter.org/programs- classes/GMCContentPage.aspx?nd=276

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Gwinnett Hospital System, Inc.-Dr. Acute Care NP The agency may at any time request health status reports on students at their facility. USA/Faculty and Naila Avery Students please find placement information on the Lawrenceville, Georgia following website: www.gwinnettmedicalcenter.org.

Gwinnett Hospital System, Inc.-Dr. FNP Only See Process Change Document Garimella FNP students only – preceptor Dr. Prasad Lawrenceville and Duluth, Georgia Garimella. Faculty complete and Student review Exhibit “A” Permitted Activities of the Student Student orientation materials are now on our website: http://www.gwinnettmedicalcenter.org/programs- classes/GMCContentPage.aspx?nd=276 Gwinnett Hospital System, Inc.-Dr. Adult-Geron Acute NP The agency may at any time request health status Adult-Geron Acute reports on students at their facility. USA/Faculty and Gregory Mauldin portion of Dual Role Students please find placement information on the Lawrenceville, Georgia following website: www.gwinnettmedicalcenter.org.

Gwinnett Hospital System, Inc. (Dr. Acute Care NP Only See Process Change Document Michael Press Only)

Lawrenceville and Duluth, Georgia – preceptor Dr. Michael Press only. Students must review Exhibit “A” Permitted Activities of the Student. Please see website for placement information: www.gwinnettmedicalcenter.org. Gwinnett Hospital System, Inc. BSN, MSN, DNP BSN, MSN, DNP programs. The agency may at any time request health status reports on students at their Lawrenceville, Georgia facility. USA/Faculty and Students please find placement information on the following website: www.gwinnettmedicalcenter.org

Agency Name Programs Agency Requirements Covered Hancock Medical Center Undergraduate and Bay St. Louis, Mississippi Graduate Nursing

Hany S. Aziz, MD, Inc. MSN, DNP Bakersfield, California Harbin Clinic Undergraduate and Graduate Nursing Rome, Georgia Harborview Medical Center BSN, MSN, and Please provide: DNP Beginning dates and length of experience (to be Seattle, Washington mutually agreed upon at least one month before the beginning of the clinical education program);

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Number of students eligible to participate in the clinical education program; Specific days, hours and locations for the clinical education program; Specific learning objectives and performance expectations for students; Specific allocation of responsibilities for the faculty Liaison, clinical education Supervisor, and Preceptors, if any, identified elsewhere in this Agreement; Deadlines and format for student progress reports and evaluation forms. School will obtain evidence of current immunizations prior to students starting placement at the Training Site and will provide evidence of student immunizations to the Training Site immediately upon request. Training Site immunization requirements are based on Centers for Disease Control guidelines and University of Washington Medicine policy. Specific Background Check Requirement: School agrees to request the following criminal background checks on all students to be placed at Training Site and will only refer for placement those students for whom they have verified successful completion of these background checks: 1.) National Check using “A-Check” (http://www.acheckamerica.com/) 2.)Washington State’s WATCH check, which must include the Child and Adult Abuse Law (CAAL) check pursuant to RCW 43.43.830-.842, which can be completed via the Washington State Patrol background check process (http://www.wsp.wa.gov/crime/chrequests.htm) 3.) Search of List of Excluded Individuals/Entities managed by the Office of Inspector General for the U.S. Department of Health & Human Services (http://exclusions.oig.hhs.gov/search.aspx) and 4.) Search of the Excluded Parties List System managed by the General Services Administration (https://www.epls.gov/). Background checks must have been completed less than one year prior to the start of the education program. School will obtain evidence of successfully completed background check prior to students starting placement at the Training Site. Hardin Memorial Hospital Nursing Programs Student must complete Influenza Questionnaire, Report of Tuberculosis Screening, and Exhibit B. A Elizabethtown, Kentucky negative TB skin test administered within the past three months from the start of the clinical experiences or a current chest x-ray. Written documentation of two (2) live measles, mumps, and rubella (MMR) vaccines given no less than one month apart, after the first birthday, if born on or after January 1, 1957; or provide written documentation of laboratory evidence of immunity to rubeola, mumps, and rubella; or written documentation of a physician- diagnosed infection of rubeola, mumps or rubella in the event of a positive TB skin test. Written documentation of a completed series of Hepatitis-B vaccine or documentation of informed refusal of the vaccine;

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Written documentation that students have received a tetanus/diphtheria booster if ten years have elapsed since their last booster; Written documentation of laboratory evidence of immunity to varicella (chickenpox) or written documentation of appropriate varicella vaccination; Completion of Influenza Reporting Questionnaire (between October 1 and March 31st); form attached. Proof of US Citizenship or appropriate student visa. Harrington Memorial Hospital, Inc. Nursing See Exhibit A-Infection Control Guidelines. Student: Must have CORI (Criminal Offender Record and Harrington Physician Services, Information) check performed by Agency. Student Inc. must obtain and maintain health and accident Southbridge, Massachusetts insurance during the clinical experience.

Harris Regional Hospital and Swain MSN and DNP USA/Faculty: Provide to Hospital no less than one month prior to each student’s clinical experience the County Hospital (Duke Life Point) following; Sylva, North Carolina Expected level of experience each student will be assigned. Expected learning objectives for each student. Summary of each student’s education and clinical experience field work. Background check of the student no more than ONE YEAR OLD.

Hattiesburg Clinic, PA (covers all BSN, RN-BSN, Hattiesburg Clinic locations) MSN, DNP Hattiesburg, Mississippi Haven Hospice Undergraduate and Please see the Agency’s Code of Ethical Graduate Students Gainesville, Florida Business Conduct at the bottom of the first page of the first page http://www.havenhospice.org/ Hawai’i Pacific Health (to include: MSN, DNP Students must review Exhibit “A” Standards of Kapi`olani Medical Center for Women & Conduct, USA must submit request for clinical and the immunization documentation to agency’s Children, Pali Momi Medical Center, Straub Coordinator (Stephen Bowman Medical Center, Wilcox Medical Center and [email protected]) four Kauai Medical Clinics) weeks prior to student placement. Honolulu, Hawai’i Renewal in process-set to expire 12/31/2018 HCA HealthOne (covers: Centennial Nursing USA/Faculty: Complete Exhibit C-Attestation. Medical Plaza, North Suburban Medical Center, Provide to site the rotation schedule. See Addenda A North Suburban Medical Center NE ER, North for site contact information. Suburban Medical Center NW ER, Rose Medical Center, Presbyterian/St. Luke’s Medical Center, Student: Complete Exhibit A&B. Saddle Rock ER, Sky Ridge Medical Center, Tuberculin skin test performed within the past Spalding Rehab Hospital, Swedish Medical Center twelve (12) months or documentation as a Swedish Medical Center Belmar ER, Swedish previous positive reactor; Proof of Rubella and Southwest ER, Rose Medical Center Stapleton Rubeola immunity by positive antibody titers or two ER, The Medical Center of Aurora Main Campus, (2) doses of MMR; Proof of Varicella immunity, by The Medical Center of Aurora North Campus) positive history of chickenpox or Varicella immunization; Proof of Influenza vaccination during Denver, Colorado the flu season, October 1 to March 31, (or dates defined by CDC), or a signed Declination Form; and

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Proof of Hepatitis B immunization or declination of vaccine, if patient contact is anticipated. HCA Health Services of Tennessee, BSN, MSN, DNP USA must complete Exhibit A-Roster prior to clinicals. USA is being asked to also provide, upon d/b/a Centennial Medical Center request of Facility for Facility audit purposes, Nashville, Tennessee documentation of student alcohol and drug testing.

HCA North Texas (name change Nursing USA/Faculty please send completed Attestation Form (Exhibit C) to the hospital in which your student Medical City Healthcare, please is using as a clinical site. use this name on the LON) (to Note: Exhibit C states faculty and students have include met and have evidence on file...this is only for Medical Center of Alliance, on-site faculty. Denton Regional Medical Center, Students must complete Exhibit A (Statement of Responsibility) and Exhibit B (Confidentiality Green Oaks Hospital, Columbia Las Colinas Statement) prior to beginning clinical rotation. Medical Center, Medical Center of Arlington, Medical Center of Lewisville, Medical Center of McKinney, Medical Center of Plano, Medical City Dallas Hospital, North Hills Hospital, Plaza Medical Center of Fort Worth) Irving, Texas Health Care Authority of the City of Undergraduate and Prior to clinicals , each student shall be skin tested Graduate Nursing for TB, with the initial 2-step test and proof of annual Anniston (formerly Northeast Alabama Students TB testing, provide written evidence thereof to Regional) Facility. Anniston, Alabama Student: Must complete facility’s orientation and acknowledgment sheet through agency and return to agency’s Human Resources prior to clinicals. Health Care Centers in Schools, MSN, DNP USA/Faculty: Facility contact: Sue Catchings- [email protected], Yolanda Inc., d/b/a Health Centers in Schools Lastrapes - [email protected], Sean Baton Rouge, Louisiana Nguyen - [email protected]. Students: Complete attachments 1-3. HealthCare Partners, LLC (JSA) BSN, MSN, Post Students: Must provide own health insurance. Must Masters Cert., DNP complete Exhibits A&B. Please see complete list of covered clinics (FL, CA, NV, NM) http://llc.healthcarepartners.com/Abou tOurCompanies/OurMedicalOffices.asp x St. Petersburg, Florida Health First Medical Group, LLC MSN, DNP Before requesting this site. Student’s USA Faculty must contact Clinical Affairs for specific Melbourne, Florida directions.

Student: Provide Student CV to Agency. Shall meet the standards as described in Florida Statues Section 435.04 for a level 2 background screening. Must complete current mandatory requirements as determined by Health First Center for Learning and Department. Sign a Release of Responsibility and Confidentiality Statement. If experience is between the hours of 5pm - 7am check in with Safety and Security Department. Students

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered must show their yellow Student badge and sign in as a Student. Health Texas Provider Network NP USA/Faculty: At least 90 days prior to beginning of clinical, faculty shall furnish to Facility clinical rotation Dallas, Texas requirements (Exhibit A- attached). At least 10 days Renewal in process-set to expire prior to clinicals, faculty shall furnish to Facility student name, health status (which shall include 8/1/2018 evidence student has met the immunization and other health status requirements facility may request), report of student: letter of verification stating that results of background check and drug screen show no negative or adverse information;

Student: Must sign Exhibit B. Health Texas Provider Network and Advanced Practice Provide student name, level of clinical training and Nurse length and dates of the student’s assignment to Baylor All Saints Medical Center Hospital and Group, along with such information as may be reasonably requested such as, written proof of an active and unrestricted nursing license issued by the State of Texas, immunizations, or other health status requirements.

Student: Complete Exhibit A. Must maintain adequate health insurance throughout clinicals at hospital. Health Texas Provider Network and Advanced Practice Student must complete Exhibit A. Student must Only maintain health insurance during their clinical Baylor Scott & White Medical experience at the hospital. Center-Irving Irving, Texas Contact: Susan Shipp [email protected] Health Texas Provider Network and APRN Student: Must participate in the orientation provided by the Hospital and Group. Must maintain adequate Baylor University Medical Center health insurance throughout clinical experience. Dallas, Texas Complete Confidentiality Agreement. Healthcare Network of Southwest Nursing University will request and must receive approval from Agency the number of students, faculty, and Florida (Collier Health Services, Inc) time periods for use of facility prior to the start of any Immokalee, Florida educational experiences. Contact: Treneice Collins (HR Recruiter) 239-658-3147 [email protected] HealthPartners Institute Nursing Programs USA Faculty Contact: Willie R. Braziel, BSc. HA St. Paul, Minnesota [email protected]

Must contact site at least 30 days prior to the start of anticipated clinics.

Healthsouth Rehab Corporation Mobile, Alabama Healthy Steps Internal Medicine Undergraduate and Graduate Nursing Silver Spring, Maryland Heartland Regional Medical Center BSN, RN-BSN, MSN, USA/Faculty: Provide a list of students and clinical DNP rotation schedule at least two weeks prior to the d/b/a Mosaic Life Care beginning of experience. St. Joseph, Missouri Renewal in process-set to expire Student: Must complete any orientation/training required by Facility, document completion if 12/31/2018 applicable

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered (https://www.mymosaiclifecare.org/students ).Must obtain health insurance. Must obtain a Missouri background check pursuant to the provisions of R.S. MO 660.317 prior to experience. Background check recommendations can be found at https://www.mymosaiclifecare.org/students. At a minimum, each background check shall include a review of the following: ● Missouri Highway Patrol Criminal Background Check ● Other State Criminal Background Check (previous residences other than MO/KS in past 7 years) ● US Dept. of Health and Human Services and the Office of Inspector General's database for individuals and businesses excluded or sanctioned from participating in Medicare, Medicaid, or other federally funded programs ● General Services Administration/Excluded Parties List System ● Missouri Sex Offender Registry ● Other State or National Sex Offender List (previous residences other than MO/KS) ● Name, Social Security Number and Address Verification ● United States Treasury — SDN and Blocked Persons List Web Site. Henry Ford Health System Nursing USA/Faculty: Provide in writing at least 30 days before clinicals and length of clinical experience to Detroit, Michigan agency. Provide to agency the name, health status, evidence of coverage of student’s health insurance, and chest x-ray or tuberculosis skin test, if requested by agency at least 4 weeks prior to clinical experience. USA will cause each student to submit to a drug screen of a scope and within time periods satisfactory to HFHS and will ensure that the results of said screen are sent directly from the investigator to SCHOOL. SCHOOL shall advise HFHS of any history of positive results related to any student participating in the program of which SCHOOL is aware. USA please go to ACEMAPP.org to complete the student placement requirements. Agency contact is Dr. Mary [email protected] Students: Must complete Exhibit A. May be required to submit prior to clinical experience to a physical examination at HFHS or one of its affiliates, including a tuberculosis test and rubella vaccine, and/or to furnish HFHS with a certification and report of a prior physical examination. High Point Regional Health RN-BSN, MSN, DNP USA/Faculty: Complete Exhibit B. Provide objectives for student’s clinical experience. Provide to Agency, High Point, North Carolina the names of students at least one month prior to the beginning of experience. Student: Completed Exhibit A-HIPAA Confidentiality Agreement.

Highland Community MSN, DNP Please see Exhibit C for specific requirements. Students are required to submit fingerprints to Hospital/Highland Physicians Clinic agency. Students shall maintain comprehensive Picayune, Mississippi healthcare insurance during clinicals. HighPoint Health System Graduate Nursing Students: Required for all students entering into a Programs clinical experience have undergone a urine drug

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Gallatin, Tennessee screen complying with Agency’s policies within the thirty (30-days preceding commencement of clinical experience. Must carry health insurance during the clinical experience. Have received the following immunizations: FPD tuberculin skin test or, if they have had a previous positive skin test, an initial CXR followed by a yearly medical screening. Positive serology of immunity to Rubella and Rubeolla or MMR vaccination. Hepatitis B vaccinations or waiver indicating refusal. Positive serology of immunity to varicella or immunization. Background check must be completed within the 90-day period immediately prior to the student’s initial clinical placement Hoag Memorial Hospital Nurse Practitioner, USA/Faculty: Provide the names of Students and their assignments to agency. Student: Complete the Presbyterian Clinical Nurse Specialist and Acknowledgement of Non-Employee Newport Beach, California Executive Nursing Status/Agreement of Student (Exhibit A). Admin. Holland Hospital Undergraduate and USA/Faculty: Provide to the Hospital number of Graduate Programs students and their dates for clinical experience. Holland, Michigan Hollywood Presbyterian Medical Nursing Complete Exhibit A&C. Submit a copy of all required documents from Exhibit B no later than two weeks in Center advance of the first date of the clinical experience. Los Angeles, California Background check must have been completed within 6 months prior to first date of the clinical experience. USA Faculty must notify the Hospital of cancelled rotations and informational changes on pre-approved rotation dates, confirming Student’s clearance status, and submitting requests for additional rotations, no less than two weeks in advance, for review and approval by Hospital’s Healthcare Educator. Duration of Student Rotations is expected to be twelve (12) months. Holzer Health System (Holzer Nurse Practitioner USA/Faculty: See Exhibits A-C for Requirements. Gallipolis, Holzer Medical Center-Jackson, Provide written request to the Education Department at Agency. Provide names of students and dates of Holzer Clinic, Holzer Senior Care, Holzer Educational Experiences no later than thirty days Assisted Living) (30) prior to students’ arrival. An 18-panel drug and Gallipolis, Ohio alcohol screening and a criminal background check consistent with the testing standards that Holzer Renewal in process-set to expire requires of all employees prior to hire and with 11/30/2018 results acceptable to Holzer in order for Student to participate in an educational experience on Holzer premises. Positive screens are subject to confirmatory testing. During the Educational Experience at Holzer, students are subject to Holzer’s Drug Free Workplace Act Policy, including reasonable suspicion and post-accident drug and alcohol testing by Holzer.

Student: Must complete Exhibit D. Honor Health (Scottsdale MSN, DNP Agency contact: Jennifer Scrabeck 480-324-7222. Healthcare) [email protected] Scottsdale, Arizona Hospital of the University of Graduate Nursing USA/Faculty: Provide Agency with adequate Pennsylvania Programs written information on the numbers and names of Students being assigned to Agency and

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Philadelphia, Pennsylvania clinical experiences needed. USA shall advise Agency at that time if the Student(s) being assigned to the Program at Agency are also employees of Agency.

Student: Complete Exhibit A-Student Responsibility Form. Students pass a pre- entrance physical examination, which shall include but not be limited to proof of routine immunizations or disease immunity, including measles, mumps, rubella, and Varicella, as well as testing for tuberculosis. Evidence of Hepatitis B immunization (or evidence of informed refusal of Hepatitis B immunization), annual influenza vaccination and any other vaccinations/immunizations as FACILITY may require from time to time is also required for all Program participants. Students shall make arrangements for the performance of lawful criminal background checks and child abuse clearances in accordance with Pennsylvania Child Protective Services Law Housing First, Inc. (15 Place) BSN, MSN, DNP Mobile, AL Houston Medical Center Undergraduate and www.hhc.org Graduate Nursing Warner Robins, Georgia Students HSHS Medical Group, Inc. (covers Nursing USA/Faculty: See Exhibit C for program all HSHS Medical Group clinic sites specific requirements. and priority care locations, Evidence of student certifications, (Hospitalist and Intensivist at HSHS vaccinations, etc. Where applicable, the St. John’s Hospital) within the state School shall provide evidence that a Student of Illinois) has met all vaccination and certifications Springfield, Illinois requirements, as required by law and Facility policy, which may include, without limitation, CPR certification, hepatitis B vaccination, and OSHA compliance for prevention of transmission of blood borne pathogens and TB, as described in further detail in Exhibit C.

Criminal background check and drug screen compliance. Where applicable, a criminal background check and drug screen, as specified in Exhibit C, and as required by and acceptable to the Facility, are required of each placed Student prior to participation in the clinical rotation. It is the School’s responsibility to ensure that the background check and drug screening have been completed and that Students with unacceptable results will not participate at sites where Students with such results are forbidden by policy. HSOC, Inc. (Children at Hughes MSN and DNP See Requirements listed within Exhibits B-1 and C.

Spaulding) USA/Faculty: Provide Agency with overall objectives of experience.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Atlanta, Georgia Student: Must sign Participant Agreement Tracking Form. Please read Exhibit B-1 Participant Agreement. Hunt Regional Healthcare BSN, RN-BSN, Greenville, Texas MSN, DNP Huntsville Health System (to include: Nursing Faculty and Students please read all Huntsville Hospital (main), Huntsville the instructions including any on the Hospital for Women & Children, next page. Madison Hospital, Parkway Medical Please note: - All requests (undergraduate, Center, and Heart Center, Inc., Athens- graduate, and instructor) must come through your Limestone and Hospital Huntsville college or university. Please do not send individual Hospital Physician Care) students or instructors to the hospital campus to Huntsville, Alabama request that a badge form be signed "on-the-spot." - Please use the most current version of the Non- Employee Badge Request Form. I have attached it to this email. - For schools submitting badge requests for multiple students, please provide a typed master list of the names of the students. The names on the handwritten forms are incredibly difficult to read and this step allows Security to expedite the processing of the forms. - Once we receive the forms in the Clinical Nurse Practice office and forward them to Security, please allow at least 3 to 5 business days for Security to process the forms before students obtain their badges at the Security office.

USA Faculty please, visit the following website for any clinical placement: http://www.huntsvillehospital.org/schools-with- clinical-affiliation. Also available through this link is the Non-Employee Badge Request form that the student will need to complete and fax to this office: 256-265-1955. The badge request is the only paperwork we need - schools maintain all other copies of the modules and affirmation statements.

Student must at their own expense have substance abuse test to include, alcohol drugs, or controlled substances immediately prior to student beginning clinicals.

Huntsville Memorial Hospital RN-BSN, MSN, DNP USA/Faculty: Provide schedule indicating for time period of clinical experience. See Clinical Checklist. Huntsville, Texas Student: PLEASE READ Program Participant Agreement and Waiver of Claims before signing.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Iberia Medical Center MSN, DNP Agency contact: Tamekia Livingston-Willis-337-365-4945 [email protected]. New Iberia, Louisiana IHA Undergraduate and Graduate Ann Arbor, Michigan Nursing Students IHC Health Services, Inc.- NP From Intermountain’s Associate Chief Medical Officer: Intermountain Healthcare (all “The guidance from the CDC and our own internal clinics owned by IHC are covered) plan is to restrict the number of health care workers Salt Lake City, Utah who provide bedside care to a suspected or confirmed Ebola patient. We are assembling a team of experienced ICU staff who would receive advances training prior to being assigned to such a patient. …we [are] NOT to assign nursing students, medical students or other trainees to a suspected Ebola patient.”

Faculty, please report to Contract Office any students at this facility during October-April each year at end of clinical experience and if the students Influenza Vaccination. (Only if student was at any of their sites for 30 days or more). Please see exhibit B for immunization requirements. IMC Clinics ( to include: IMC Baldwin BSN, RN-BSN, Student-must have evidence of Hepatitis B vaccination Surgery, P.C., IMC Diagnostic & Medical MSN, DNP and/or positive antibody titer or presentation of the OSHA declination form. Evidence of Mantoux-two step TB skin Clinic, P.C, IMC Family Medical of testing or proof of a previous positive result. Evidence of Jackson, P.C., IMC Mobile Medical Group, an annual TB skin test of a previous positive result. P.C., IMC Cancer Surgery of Mobile, P.C., IMC Eastern Shore Adult Medicine, P.C., IMC Family Medical of Mobile, P.C., IMC North Baldwin Internal Medicine, P.C., IMC OB-GYN Associates, P.C., IMC Pediatrics and Adolescent Medicine, P.C., IMC Women’s Health Alliance of Mobile, P.C., Infirmary Health Urgent Care-Bay Minette, P.C., IMC Foley Medical Clinic, P.C., North Baldwin Family Medical, P.C. North Baldwin Pediatrics, P.C. Mobile, Alabama Infectious Disease Consultants Undergraduate and Graduate Suwanee, Georgia Students Infirmary Health (covers: Mobile Nursing USA Faculty and Students-Please see the Standards of Conduct. Infirmary Association, d/b/a Mobile Infirmary Medical Center, Gulf As a reminder, please submit all required forms at Health Hospitals, Inc., d/b/a least 2 weeks prior to your clinical start date and complete forms as required. Please refer to the Thomas Hospital, Gulf Health “Clinical Placement Guidelines for Nursing Students” Hospitals, Inc., d/b/a North Baldwin on the IH Nursing Student webpage at http://www.infirmaryhealth.org/nursing-students for Infirmary, Infirmary Health detailed information. All but the IH Student Hospitals, Inc., d/b/a Infirmary Information form may be submitted electronically. LTAC Hospital, and Escambia Each form on the IH nursing student webpage at http://www.infirmaryhealth.org/nursing-students has County Alabama Community a facility selection field and a submit button in the Hospitals, Inc., d/b/a Atmore upper section of the form. Complete the form as Community Hospital required, then select the facility where the form needs to be submitted to, and finally submit the form by

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered clicking on the submit button. You will receive a confirmation that the form has been submitted.

Faculty must provide Kaitlyn Hunt (251-435-5233) with a schedule, name of clinical instructor, and clinical instructor for each group of students indicating days of the week, hours of clinical experience, number of students, type of clinical experience, first and last date of rotation. The agency did not provide a specific form. Students must complete a 45 minute Healthstream module for orientation. Once the module has been completed by student the Letter of Notification will be returned along with the student badge and parking decal. InnovAge Great Colorado PACE Undergraduate Denver, Colorado and Graduate Nursing InPhyNet Contracting Services, Nursing USA/Faculty: Provide course objectives and ensure ongoing communication with Preceptor. Notify Company LLC and Preceptor of planned schedule of each student assignment, including name of student, level of academic preparation, and length and dates of clinical. InPhyNet Primary Care (3-way NP Emergency Room Department Students – Iberia agreement with Iberia Medical Medical Center clinicals. Center) Fort Lauderdale, Florida INTEGRIS Health, Inc. (and Graduate USA/Faculty: Must provide a roster of the names of the USA Clinical Coordinator and Students and rotation affiliated entities) Nursing Programs schedule prior to clinical. Oklahoma City, Oklahoma Students must complete Exhibit A, Student Confidentiality Agreement. Must have negative tuberculin skin test (in conformity with the Oklahoma State Department of Health’s guidelines) or negative chest x-ray. InPatient Consultants (IPC) of BSN, RN-BSN, USA/Faculty: Provide to Medical Group (IPC), a list of MSN, DNP students and their desired dates who will be participating Alabama, Inc. (in conjunction with the in clinicals under the terms of this agreement. Advise following: Springhill Medical Center, Mobile students in writing that their participation in clinicals under Infirmary Medical Center, and North Medical Groups supervision is conditioned at all times to Baldwin Infirmary) the following: North Hollywood, California All instructions given by the Provider who is supervising the Student’s Clinical Rotations. All rules and policies set forth by Medical Group and any Facility with regard to Students’ participation in the Clinical Rotation, including but not limited to, maintaining the confidential nature of patient-identifying information that is disclosed to any Student during their Clinical Rotation with Medical Group; and, Applicable policies and procedures of the Facility or Facilities where the Student is participating in a Clinical Rotation.

Student: Must complete and sign Exhibit B-Student Agreement. Must have health insurance coverage under an accident and sickness health insurance plan. InPatient Consultants of Colorado, MSN, DNP USA/Faculty: Provide to Medical Group-list of Students who will be in facility, dates and obtain approval from P.C. Medical Group. North Hollywood, California Students: Must complete Exhibit A-Student Agreement. Must carry health insurance coverage during clinicals at Medical Group.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered InPatient Consultants (IPC) of MSN, DNP USA/Faculty: Obtain from each facility, acceptance and acknowledgment of the students participation in the Florida, Inc. clinical experience. Provide student information (name North Hollywood, California (Main and dates of clinical, health status, immunization record, Ofc.) verification that student meets the University's health requirements, evidence of students health insurance coverage) to Medical Group.

Student: Must obtain and maintain health insurance coverage. Must complete and sign Exhibit B-Student Agreement. Inspira Health Network, Inc. (to Nursing USA Faculty and Students please read the Conditions of Participation/NIAHO at the following website: include Inspira Medical Center- https://www.cms.gov/Regulations-and- Elmer and Inspira Medical Center- Guidance/Legislation/CFCsAndCoPs/Hospitals.html. Vineland)

Woodbury, New Jersey IPC -InPatient Consultants of RN-BSN, MSN, This listing is an agreement for the preceptor employed DNP by IPC, an affiliation agreement must also be obtained for Missouri, Inc. (Preceptor the facility (please check the affiliation list, if agency is not Agreement Only-Must have listed please see process to establish). correlating agreement with facility) USA/Faculty: Provide to IPC a list of the students who will be in clinicals, desired dates, and obtain IPC's approval. St. Louis, Missouri Advise students in writing that their participation in the clinical experience is conditioned on adherence to: All instructions given by preceptor, all rules and policies set *Must accompany an agreement forth by IPC and any facility. Maintain confidentiality with Facility* nature of patient - identifying information that is disclosed to any student during clinical. Student: Must complete the updated Exhibit A-return to agency. Must carry health insurance. InPatient Consultants of North Graduate Nursing USA/Faculty: Provide to Medical Group-list of Students Students who will be in facility, dates and obtain approval from Carolina, P.C. Medical Group. North Hollywood, CA (Main Office) Students: Must complete Exhibit A-Student Agreement. Must carry health insurance coverage during clinicals at Medical Group.

Agency Name Programs Agency Requirements Covered Jack C. Montgomery VAMC MSN Muskogee, Oklahoma Jackson County, Oregon Undergraduate and Student must complete Exhibit A through the Clinical Graduate Nursing Affairs office. Student is responsible for all medical insurance Medford, Oregon coverage. Jackson Hospital Nursing Clinical request shall be sent to the facility at least 3 weeks prior to the start of the academic year. Provide to Hospital Montgomery, Alabama schedule and objectives for learning experience, following the guideline in Appendix A. Provide clinical request for student preceptorship clinical in order to be assigned a preceptor by following the guideline in Appendix B. Jackson Hospital BSN, MSN, DNP Marianna, Florida

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered

Jackson-Madison County BSN, RN-BSN, General Hospital, MSN, DNP West TN Healthcare Jackson, Tennessee Renewal in process-set to expire 11/19/2018 James J. Peters VA Medical Nurse Contact: [email protected] Center Practitioner (718) 584-9000, ext. 6274 Students Bronx, New York Jefferson Health Northeast Nursing See and complete Exhibits A-C. Submit to Hospital the names and educational background of each student at least 4 weeks Philadelphia, Pennsylvania prior to clinical experience. Jennie Stuart Health Undergraduate and Graduate Nursing Hopkinsville, Kentucky Students John Muir Health (JMH) MSN and DNP USA/Faculty and Students: See Exhibits C-F-2 for NO NURSE additional requirements per the agreement. Walnut Creek, California PRACTITIONER STUDENTS Students must provide evidence of their own accident insurance with benefits that are no less than $10,000. Student’s shall maintain adequate health insurance throughout the clinical experience. Johns Hopkins Bayview MSN USA Faculty must submit Exhibit A&B(NNP ONLY) Schedule Medical Center DNP NNP A (MSN and DNP) (sites, placement dates, and number of Baltimore, Maryland students) to agency, along with program curriculum and clinical education goals. Students shall have completed blood Renewal in process-set to borne pathogen safety training under current regulations of expire 8/31/2018 OSHA. Students must submit to: Johns Hopkins Bayview Medical Center Dept. of Nursing, Practice, Education & Research 4940 Eastern Avenue Baltimore, MD 21224 Attn.: Elaine Sparks, MS, RN, NEA-BC Professional Development Specialist Phone: 410.550.0179 Fax: 410.550.4254 Email: [email protected] . Students must have health insurance coverage. USA Faculty must possess a current, valid license or certificate in area of professional specialty. Johns Hopkins Hospital - MSN, DNP See below link for NP/Graduate Nursing Student Request https://goo.gl/forms/ziIYAXkpjvv3Ay1y2 Downtown Campus Baltimore, Maryland Agency contact: Laura Smith, Nursing Student Placements. The Johns Hopkins Hospital,410-583- 5257, [email protected].

USA/Faculty: Complete Exhibit A-Placement Information. At least 3 weeks prior to clinical. Complete Exhibit 1. See Schedule 1 for Student Information Required.

Students: Must provide background check results submitted to Joseph Phelps, HR Investigator, The Johns Hopkins Health System Corporation, 1101 E. 33rd Street, Baltimore, MD 21218, 443-997-7366, [email protected].

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered JPS Health Network DNP USA/Faculty: Provide Agency with a schedule for each semester EMPLOYEES when Students are to be in any Agency. The schedule shall include: Fort Worth, Texas ONLY each Student’s name, the clinical unit at Agency where each Student will work, and the hours for each day that each Student will be at Agency. Student: Must complete the Dallas-Fort Worth Hospital Council Foundation’s Standard Hospital Student Orientation (“Standard Orientation”) and pass the Standard Orientation exam with a 100% post-test score.

Agency Name Programs Agency Requirements Covered Kaiser Foundation Health Plan of Graduate Nursing Agency contact: Janny Ukaegbu, Internship Program MSN, DNP Coordinator, [email protected]. the Mid-Atlantic States Rockville, Maryland USA/Faculty: See Exhibit B for immunization requirements.

Provide the following at least 30 days before commencement of student’s clinicals. Name, address and telephone number, e-mail address, emergency notification information and other contact information as may be required; Information about each Program Participant’s health care insurance and providers (e.g., primary care physician); Confirmation of the agreed upon dates and hours of such Program Participant’s assignment at the Facilities; Copy of the signed Confidentiality Agreement attached hereto as Exhibit C; Certification, or proof of compliance with the requirements for immunizations and vaccinations, as set forth in Exhibit B, and the background screening.

Students: Complete Exhibit C. Must have health insurance coverage. Kaiser Foundation Hospitals/Kaiser RN-BSN, MSN, USA/Faculty: See Exhibit B (Bloodborne Foundation Northwest DNP Pathogens/TB Training Components-2 pages).

Clackamas, Oregon Keesler Medical Center, 81st MSN Medical Group, All students must check in with Major Garrett Miller ([email protected]). He will assist with all Keesler AFB, Mississippi clinical rotations at Keesler. Kennedy Krieger Institute Nursing USA/Faculty: Provide name(s) of students to facility (Elizabeth [email protected]) at Baltimore, Maryland least one month prior to commencement of clinicals. Kenner Army Health Clinic (includes MSN, DNP Wilkerson Pediatric Clinic) Fort Lee, Virginia Kettering Health Network USA/Faculty: Provide written request to assign students to facility, to include student names and Dayton, Ohio dates 30 days prior to clinicals. Please see Exhibit A for Agency's health and immunization requirements per the Ohio Dept. of Health. Sign Exhibit C.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Students: Provide proof of health insurance to facility. Must sign Exhibit B - Student Orientation Form. Kidzcare Pediatric PC Undergraduate and Graduate Nursing Wilmington, North Carolina Kindred Hospital of Seattle-First Hill Undergraduate and Please complete the attestation letter. Student Graduate Nursing Seattle, Washington must complete the confidentiality agreement students from agency, King’s Daughters’ Health MSN, DNP USA Faculty must provide the number of students, proposed schedule planned, and academic status of Madison, Indiana each student participating in clinicals to the agency ([email protected]). Students are responsible to meet Hospital health and safety screening requirements set forth in Exhibit A (which includes OSHA & HFAP Compliance certification) and Hospital Non-associate Orientation Manual prior to beginning clinicals. Knox Community Hospital MSN, DNP USA/Faculty: Must utilize the Student Clinical Process (Part I). Notify at least one semester prior to Mount Vernon, Ohio the beginning of clinical with verification of all information contained on Part II Clinical Form. Provide OSHA education on Protection from Blood Borne Pathogens to students. Provide HIPAA training. Please note Preceptor Compliance with the Ohio Board of Nursing attached.

Student: Provide information to facility within Part III Clinical Instructor Student Form.

Agency Name Programs Agency Requirements Covered L&M Medical Group (LMMG) Nursing Students must maintain health insurance coverage at all times during their clinical. New London, Connecticut Lafayette General Medical Center BSN, RN-BSN, MSN, Students, please inquire with facility if the (agreement covers facilities that fall under DNP facility/clinic would fall under Lafayette Health Ventures, Inc.-If so, the USA paperwork will need to Lafayette Health Ventures, Inc., (covers indicate as such. Lafayette General Southwest-contact Monica [email protected]) NP student will need to contact Amy Boudreaux- Lafayette, Louisiana [email protected]—at least 3 weeks before expected start date.

Copy of CV to include contact information, Copy of any certifications: ACLS, BLS, etc., copy of TB test result, Copy of License, copy of current malpractice insurance, exact dates the student will be at facility and the physician that they will be with. They will also need to attend the hospital’s orientation that is only offered twice a month. Monica Guidry (289- 7130) [email protected] will contact student to set that up at facility.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Lake Charles Memorial Hospital Undergraduate and Graduate Students Lake Charles, Louisiana Lake City Medical Center MSN and DNP USA/Faculty: Complete Exhibit C-Attestation Student: Complete Exhibits A and B. Must pass a Lake City, Florida1 medical examination acceptable to Hospital prior to clinicals at least once a year. Lakeland HealthCare Graduate Nursing Contact: Programs Andrew J (AJ) Summerville, PA-C St. Joseph, Michigan Advanced Practice Provider Faculty Liaison [email protected]

USA/Faculty: Notify Agency at least 60 days prior to the beginning of the clinical experience with the dates, expected hours for each student, and level of academic and pre-clinical prep for each student.

Agency requires the following of each Student These documents will be kept at USA and made available for review by the Agency in the event of a Joint Commission or State Inspection. USA will provide Agency documentation verifying names of Students who have completed requirements listed below prior to clinical rotation start: Basic documentation: • Orientation packet and completion form- located on line at https://www.lakelandhealth.org/student Immunizations: Documentation of vaccination or titer: • Current TB test-within 1 year • Measles • Mumps • Rubella • Varicella • Hepatitis B • Influenza Other: 5 panel drug screen and national criminal background check to be completed upon acceptance into program of study requiring clinical time at facility. Results not older than 6 months from clinical start date.

Fingerprint Information: If a Student will have regular, ongoing, and direct access to any of the patient/resident populations listed below for 121 hours or more, they will be required to obtain fingerprints prior to beginning clinical privileges:

Pine Ridge Rehabilitation and Nursing Center, Stevensville Lakeland Regional Medical Center, St. Joseph- Psychiatric Services Lakeland Homecare Lakeland Hospice

Fingerprints must be obtained utilizing Agency’s authorization code. Information regarding this process will be provided by contacting the Manager

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered of Recruitment and Onboarding in the Human Resources Department.

Lakeland Medical Center MSN, DNP New Orleans, Louisiana Lakeview Regional Medical Center MSN and DNP USA/Faculty: Must complete Exhibits C & D Attestations. (UHS-Tulane Medical Center) Covington, Louisiana Student: Must complete Exhibits A & B. Must pass a medical examination acceptable to Hospital prior to clinicals, at least once a year. Lakewood Regional Medical Center MSN, DNP USA Faculty: Coordinate assignments and rotation plans with facility. Participate with the students in Lakewood, California Hospital's Quality Assurance and related programs. Student: Must complete Exhibits A & B. Must view videotape regarding Hospital's patient information policies and practices provided by Hospital and achieve a passing score at end of video. Must obtain health insurance coverage.

Lane Regional Medical Center Undergraduate and Graduate Students Zachary, Louisiana Landstuhl Regional Medical Center MSN, DNP Education Contact: Robert L. Dennis, Jr. APO AE [email protected] Laurel Oaks Behavioral Health RN, RN-BSN, MSN, DNP Center Dothan, Alabama Lawrence & Memorial Hospital New MSN Programs USA/Faculty: Submit to Agency for final approval at least 30 days prior to each clinical experience name London, Connecticut of student, description of the type of clinical experience needed, dates needed, and the curriculum plan. Lee Memorial Health System BSN, RN-BSN, MSN, LEE MEMORIAL EMPLOYEES ONLY DNP (covers: LMHS Psychiatric USA Letter of Notification (LON) is not required for Consultation, Gulf Coast Medical this site. Facility will provide an approval letter. This Center, Health Park Medical Center, must be sent to USA Clinical Affairs.

Cape Coral Medical Center, and USA/Faculty and Student: Complete Exhibit B- Lee Memorial Hospital, also Student Attestation. includes Lee Physician Groups) Cape Coral, Florida 7/25/2018-Agency requested to terminate the agreement upon the expiration date-not renew. Legacy Health BSN, RN-BSN, MSN, USA/Faculty: Please see exhibit B for required DNP standards of clinical experience. Contact agency for Portland, Oregon student assignments no later than one month prior Renewal in process-set to expire to start of clinicals. Contact-Debra Henry, MSN, RN Nursing Education & Practice Specialist 12/31/2018 Clinical Practice Support Legacy Health [email protected] 503-413-3247 Student: Students must hold a current unrestricted Oregon or Washington RN license. Must have

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered completed education in OSHA recommended safety guidelines (including fire & electrical safety, personal protective equipment, hazard communications, and infection prevention practices). Must also have had blood-borne pathogen training in accordance with OSHA guidelines.

Leonard J. Chabert Medical Center NP Student: Complete Exhibit A. Must receive orientation packet from facility regarding patient Houma, Louisiana information privacy policies and practices. (Separate agreement-not covered USA/Faculty: Agency Contact: Azalea Poche’- Azalea.Poche’@ochsner.org or by phone at (985) under Ochsner Agreement) 873-1819 Please contact Ms. Poche’ for all clinical rotations and observations at least 6 weeks prior to start date. LewisGale Montgomery MSN, DNP USA/Faculty: Complete Exhibit C and Addendum A. Students: Must complete Exhibits A & B. Complete Blacksburg, Virginia the Attestation for Employee Health and Other Renewal in process-set to expire Student Compliance Requirements. 12/13/2018 Lexington County Health Services Nursing Faculty must be licensed, registered or certified by the state of South Carolina. District-Lexington Medical Center Faculty: Submit a final written roster of names of (cover the Physician Group also) the participating students one week prior to the West Columbia, South Carolina beginning of the rotation. Criminal background check must be done within 90 days of student’s first rotation at facility. Please read, student list of requirements Life Net Psychiatry Undergraduate and Graduate Nursing Mandeville, Louisiana Lighthouse Academy Undergraduate and Graduate Nursing Prichard, Alabama Students Linden Oaks Hospital RN-BSN, MSN, DNP Student must maintain comprehensive health insurance during clinical experience. Naperville, Illinois Little River Healthcare/Rockdale Undergraduate and USA/Faculty: USA CON Assistant Dean for Graduate Nursing Clinical Affairs must complete the health report Clinic/Cameron Clinic for student. Rockdale, Texas Submit to Agency three weeks prior to the beginning of each clinical rotation, a schedule indicating the number and names of Students who will be participating and the name of their Clinical Faculty. Required that if Students may be at risk for occupational exposure to blood or other potentially infectious materials, Students will be: Trained in accordance with the Occupational Safety and Health Administration’s (OSHA) Occupational Exposure to Bloodborne Pathogens Final Rule 29 CFR Part 1910.1030, as published in the Federal Register Friday, December 6, 1991 Trained in the modes of transmission, epidemiology and symptoms of Hepatitis B virus (HBV) and Human Immunodeficiency (HIV) and other Bloodborne pathogens Trained in the methods of control that prevent or reduce exposure including universal precautions,

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered appropriate engineering controls, work practices and personal protective equipment Provided information on the hepatitis B vaccine, its efficacy, safety, method of administration, and benefits of being vaccinated Vaccinated for HBV or have begun the vaccination series for HBV or have signed a refusal to acquire HBV vaccination That proper follow-up evaluation is provided following any exposure incident. Loma Linda University Medical Graduate Nursing USA/Faculty: Provide Student list and description of MSN and DNP training requirements to Agency no later than 14 Center, Loma Linda University days prior to clinical. Children’s Hospital, Loma Linda University East Campus Hospital, Students: Must carry their own health insurance. Loma Linda University Behavioral Medicine Center and Loma Linda University Medical Center-Murrieta Loma Linda, California Longview Regional Medical Center MSN Nurse Student: Complete addenda 4-6, submit to agency. Practitioner Only Please, see requirements on each addendum). Longview, Texas Must have a negative TB skin test within the past year or in the event of a positive TB skin test, a chest x-ray within the past three years. Completed series of Hepatitis B vaccine. Must have health insurance during their clinical rotation. Lovelace Health System BSN, RN-BSN, MSN, Students must have Drug and Background DNP screening (Exhibit B-specifically: Caregivers Albuquerque, New Mexico Criminal History Screening: This report is conducted by the New Mexico Department of Health and encompasses a nationwide criminal history screening as well as “ink” fingerprinting. The NMDOH screening receives arrest and conviction information reported not only in New Mexico but all arrests and convictions reported nationwide to the FBI. The Caregivers Criminal History Screening Program maintains a database of criminal record information and a registry of all caregivers screened through the Department of Health. It also offers an administrative reconsideration process that allows caregivers to request a reconsideration of the results of a disqualifying conviction, thus allowing avenue for care providers to retain valuable and/or long-term employees. Other program benefits include: discourages potential applicants with criminal felony convictions from applying for employment in a health care environment; locates individuals with outstanding warrants and/or parole violations; encourages care providers to be more cautious in the applicant screening process prior to offering employment and discovers individuals who may have falsified their application and are currently employed in the health care environment and have disqualifying convictions. The search mechanism employed is designed to identify any individuals who have sought to disguise their identity and who have a criminal record-the System for the Hospital

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered uses is Hirease, Inc., ) completed and verified by USA’s Clinical Affairs Dept. The student must complete and sign Exhibit C (Statement of Responsibility).

USA faculty must provide a roster of the names of the Clinical Instructors and Students, along with the rotation schedule. Any USA Instructors that will be on-site are required to have a New Mexico license. Licenses of the Instructors must be provided to the System Coordinator prior to the beginning of clinicals.

USA must provide verification of immunizations and tests at least three days in advance of arrival at Facility.

Students are not permitted to undertake any clinical patient activity without supervision of Instructor, never permitted to perform (i) double-check on medications or blood products; or (ii) begin or discontinue blood products, chemotherapy, or experimental drugs and therapies. Students are never permitted to accept orders from physicians or other health care professionals in person or by telephone, or call a physician or physician's office to obtain an order. Lou Ruvo Center for Brain Health - MSN USA/Faculty: University must attest that each Student that University sends to CCN has had a negative FBI Cleveland Clinic fingerprint background check result with in the past Las Vegas, Nevada twelve (12) months. CCN shall not be responsible for the cost of a Student’s criminal background check. University shall maintain such documentation in the Student’s file. University will only send Students having no criminal history to CCN and will provide verification of a negative background check to CCN’s clinical supervisor or designated representative. Students with positive background checks will be asked by CCN to complete a Background Information Release form and their records will be reviewed by CCN to determine clinical eligibility. The University will not participate in this process.

Students: Students will be required to complete Cleveland Clinic’s Center for Online Medical Education and Training (“COMET”) online education modules on topics which include Basic Stroke Competency, Code of Conduct, Diversity and Inclusion, Emergency Management, HIPAA and Information Security, HIPAA Overview, Introduction to Environment of Care, Patient Safety, Preventing Occupational Exposure to Bloodborne Pathogens, Preventing Occupational Exposure to TB, Safety Event Reporting System (“SERS”), Vulnerable Populations and any additional modules deemed necessary to comply with federal and Joint Commission standards before beginning their CCN clinical experience. Although the COMET modules were created for CCN employees, all Students will be held accountable for the content found in each module. Must complete Exhibits A&B. Must carry medical insurance coverage and provide certificate of insurance to facility.

Lourdes Physician Group, LLC RN-BSN, MSN, DNP See Attachments 1-3 for completion.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Lafayette, Louisiana Lutheran Hospital of Indiana MSN, DNP USA/Faculty: Please review addenda 1-3. Students: Must have negative TB skin test within Fort Wayne, Indiana the past year or, in the event of a positive TB skin test, a chest x-ray within the past 3 years; or provide evidence of no TB disease per negative result of interferon-gamma release assay blood test (T-Spot or Quantiferon Gold) within 12 months of student clinicals at facility. Must complete and sign addenda 4 & 5 submit completed forms to agency.

Lyster U.S. Army Health Clinic MSN, ADVANCED Training for an MSN degree and Advanced Family FAMILY NP NP. USA must notify agency 30 days prior to Fort Rucker, Alabama clinicals: names, dates and hours of requested students. Cathy Cole-Matson [email protected]

Agency Name Programs Agency Requirements Covered Kindred Hospital of Seattle-First Hill MSN and DNP USA/Faculty: At least 30 days before the beginning of the clinical experience provide the names of the Seattle, Washington students, the dates, hours for the experience, and the specific clinical activities being requested. Manatee Healthcare System and MSN, DNP All instructors and students coming into the hospital between October 1 and March 31 must have either Lakewood Ranch Medical Center documentation of having received the influenza Bradenton, Florida vaccine or documentation of flu vaccine declination prior to being scheduled in any department. Marengo Family Health Center MSN, DNP Demopolis, Alabama Marion General Hospital BSN, MSN, DNP Please see Exhibit C for any additional requirements. Columbia, Mississippi Marshall Medical Center Undergraduate and Graduate Nursing Guntersville, Alabama Students Martin Army Community Hospital BSN, GRADUATE BSN and graduate students Fort Benning, Georgia Martin Memorial Health Systems, MSN, DNP Inc. Stuart, Florida Mary Black Health System-Gaffney Nursing USA/Faculty: See addenda 1&2 patient duties.

Gaffney, South Carolina Student: See Addenda 3 for required testing. Complete Addenda 4-6.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Mary Hitchcock Memorial Hospital, NP Nurse Practitioner Agreement – student must hold an RN license to practice in the State of New Dartmouth-Hitchcock Clinic Hampshire. On-site Faculty must have an APRN NH Lebanon, New Hampshire license. USA/Faculty: Discussions between faculty and preceptor will occur prior to, at the end of, and bi- weekly throughout student’s experience. Must provide to facility, a Rider Letter for each request for a Student clinical placement, to include; Specific clinical unit (s) requested, dates and times of requested clinical, name and title of faculty members responsible for facilitating the clinical, number of anticipated student, type of nursing program, copy of the course syllabus, expectations of learning experience, and evaluation criteria at least 30 days in advance of clinical. Student: Provide evidence of personal health insurance. Must provide a BLS expiration date of each student at least 30 days prior to clinicals. Provide to D H, at least thirty (30) days prior to the start of each clinical education program, evidence that on-site faculty and Students:

Have a result of positive serology of immunity to Rubella, Rubeola, and Mumps or documentation that each Student and faculty member has received two doses of Measles, Mumps, and Rubella; Have had two (2) Varicella vaccinations, positive serology of immunity, or diagnosis or verification of a history of varicella or herpes zoster by a health care provider; Have had testing for Tuberculosis as follows: Individuals who have not had Tuberculosis testing within the past two (2) years will undergo a single blood assay for Mycobacterium Tuberculosis or two- step Purified Protein Derivative (PPD) testing (TST) with documented negative results; Individuals who are tested annually will have had a negative PPD Mantoux skin test within six (6) months of clinical experience and will provide the test results; and Individuals with confirmed Latent Tuberculosis infection must provide documentation of a negative chest radiograph report. Have had the series of Hepatitis B vaccinations, is in the process of receiving the series, or supplies a waiver that indicates refusal; Have had a current annual flu vaccine; and will obtain any new flu vaccination within thirty-days (30) of distribution; Have had a single dose of Tetanus/Diphtheria/Pertussis (Tdap). Mary Washington Hospital, Inc. RN-BSN, MSN, DNP Require and certify that students meet the appropriate health requirements prior to their Fredericksburg, Virginia placement, which will include, but not be limited to, rubella/rubeola/varicella immunity, HBV immunization (unless declined by the Student in writing), TB testing (PPD) on an annual basis or as indicated by OSHA regulations, and a urine drug screen (for anyone over 18). Documentation of immunity may be verification of two MMR’s or titer.

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Require students to carry health insurance for year- round coverage, or be responsible for medical expenses incurred during this education assignment. Inform students of the Facility’s requirement that they will be required to successfully complete the Mandatory Education Learning Module and test and complete orientation for the specific department or Facility immediately prior to placement at the Facility. Maryland Primary Care Physicians, Undergraduate and Graduate Students LLC Millersville, Maryland Maury Regional Hospital d/b/a BSN, RN-BSN, MSN, USA/Faculty: Must complete Exhibit A. DNP Student: Must have BLSHC Provider CPR. Maury Regional Medical Center and Maury Regional Medical Group, Inc. Columbia, Tennessee Mayo Clinic Jacksonville MSN, DNP MAYO CLINIC EMPLOYEES ONLY-See Jacksonville, Florida UPDATED Clinical Request Info. Always look for updated changes for updated requirements. USA Faculty: Must notify Mayo School of Health Sciences before coming on Mayo Clinic campus to make necessary arrangements for access. Mayo Clinic contact is:

Contact from April-Aug.2 is Amanda [email protected]

Andi Kohlskelley Education Administration Coordinator Mayo Clinic School of Medicine Phone: 904-953-0492 Email: [email protected]

Students: All students accepted for rotation are subject to facility's admission standards. Should you have any questions, please do not hesitate to contact me. Any costs for the admission requirements are the responsibility of the student. McLaren Port Huron Nursing Students are required to have health insurance and provide evidence of such insurance to Facility. Port Huron, Michigan McLeod Medical Center-Dillon Nurse Practitioner Agency contact: Haley Hill, Student Coordinator- Human Resources-777-2595- Florence, South Carolina [email protected] USA/Faculty: No later than 2 weeks prior to beginning of clinicals submit to agency a comprehensive program of instruction for NP track. Also, include clinical assignments, dates, hours, number of students, assigned instructors and types of experiences. Verification of all required immunizations, tests including but not limited to: (i) TB; (ii) Hepatitis B vaccination series (or waiver); and

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered any other test that is now or may in the future be required by state or federal law or regulation.

Student: Criminal Background check within 90 days of admission to Program. Facility may require a drug screen prior to clinical experience.

Meadows Regional Medical Center MSN, DNP USA/Faculty: List of the names of all Students and Faculty Staff Vidalia, Georgia will be provided no less than fifteen (15) days prior to the commencement of the A.L.E. (Applied Learning Experience). ELIGIBILITY: Institution will assure that only students with satisfactory performance in the classroom and clinical practicum will be submitted for consideration. All Students and Faculty Staff, if any, are subject to Facility's HR on boarding requirements in accordance with all regulatory law including but not limited to appropriate background checks, drug testing, and Facility Immunization requirements. Provide specific written clinical behavioral objectives to preceptor prior to clinicals. Submit a schedule with names of students and their health records at least two weeks prior to clinicals (Diana Sowell-912-535- [email protected]. Medallus Medical Undergraduate and South Jordan, Utah Graduate Nursing MedHealth (covers Healthcare Undergraduate and Agency contact is the MedHealth Coordinator for Graduate Nursing Clinical Education. Facility and Family Health Centers) Programs USA/Faculty: See Exhibit A for Community Standard Dallas, Texas for Drug Screening and Background Checks-Student must meet these requirements. Student: Exhibit B -HIPAA Confidentiality Provisions. Complete Exhibit C-Confidentiality Statement. Student must provide their own health insurance. Medical Center Enterprise Nursing and Nurse USA/Faculty: Please see Addendum 1 regarding Practitioner Patient Care Services. Educate Students about Enterprise, Alabama clinical safety, OSHA blood borne pathogens standards, and tuberculosis prior to clinicals. Obtain written documentation from Students of 1. Negative TB skin test within the past year or if positive TB skin test, chest x-ray within the past three years; a completed series of Hepatitis B vaccine, having begun the series, or informed refusal of the vaccine; and any other appropriate immunizations requested by Facility. See Addendum 3. Require Students to adhere to the Substance Policy, see Addendum 4.See Addendum 5 regarding Background Consent Form.

Students: Complete Addendum 4 & 5. Medical College of Wisconsin To Be Determined by USA/Faculty: Contact USA CON Clinical Affairs to each approved submit a Program Memorandum for approval for Milwaukee, Wisconsin Program each student’s clinical experience. Memorandum Agency Requirements for Students. The Agency Designee for each Program shall forward a list of requirements, including immunizations, titers, special training, and any other requirements, as well as any applicable deadlines, to the School Designee for that Program. The School Designee for each Program shall inform the students of Agency’s requirements

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered and instruct the students to send information indicating completion dates of those requirements to Agency. Each student will be responsible for providing accurate and timely documentation of the completion of all requirements to Agency. The failure to provide accurate and timely documentation of fulfillment of all requirements shall be sufficient justification for Agency to cancel or postpone, at its option, the placement of such student. Medical Foundation of Central Nursing Programs School acknowledges that student will be required to sign an affidavit regarding the student’s prior criminal Mississippi history as required by M.C.A. §43-11-13, et seq. Jackson, Mississippi School further acknowledges and shall inform its student that should the student refuse to execute such an affidavit, then such student will not be placed at a Baptist facility located in Mississippi.

Satisfactory physical examination, including a negative nine (9) panel drug screen, PPD Skin Test, TB SKIN TEST #1 within thirty (30) days prior to start date,TB SKIN TEST #2, 1-3 weeks after initial skin test (if patient contact or hospital employee) unless documented negative TST within past twelve (12) months, or QFT or T-Spot within thirty (30) days prior to start date. If past TB test documented with 10 mm or greater induration, CHEST XRAY within six (6) months prior to start date and current symptom screen Varicella (Chicken Pox) Documented history of varicella, or Documented positive titer, or Documentation of two (2) varicella vaccinations Rubeola (Red Measles) Documented receipt of two (2) doses of live measles vaccination after first birthday. (*Please note that vaccinations given between 1963-1967 were not effective unless documented as live vaccine.), or Documented Positive Titer, Mumps Documented receipt of two (2) doses of live mumps vaccination after first birthday, or Documented Positive Titer Rubella (German Measles) Documented receipt of one (1) vaccination twelve (12) months after birth or later, or Documented Positive Titer Influenza Proof of current vaccination required October 1st through March 31st, or Required acceptable documentation of an approved medical or religious exemption Hepatitis B Vaccination Documentation of three (3) vaccinations. Merit Health Biloxi (previously Biloxi Nursing and Nurse Students must sign a Statement of Responsibility, Practitioner Students Exhibit A, and a Statement of Confidentiality, Exhibit Regional Medical Center) B. Following is required prior to clinicals by Biloxi, Mississippi Mississippi Department of Health: Background check state of MS. (addl Fee), MMR, PPD-must be within 1 year of expected date of completion of clinical rotation. Health and must have a MS background check prior to background screening attestation form (Exhibit C) being completed by University Official. Faculty must provide schedule for the length of time

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered the students will be in the facility 14 days prior to rotation. Monmouth Medical Center Nursing Programs See Exhibit A-Joint Commission Addendum (requirements). Long Beach, New Jersey Note: Background checks shall be repeated every 3 years for students continuing as a clinical affiliate. Provide a clinical assignment schedule of dates for the affiliation period of each student. MUSC-Medical University Hospital NP Agency contact: Carmen Dooley - [email protected] Authority Exhibits A-C must be completed. Medical University of South Carolina USA/Faculty: Confirming the planned schedule of and Medical University Associates student assignment, including the name and contact information for the student, level of academic Charleston, South Carolina preparation, and length and dates of fieldwork assignment. Supplying MUSC with information regarding the student’s current level of academic preparation. Must provide a signed Verification List (Exhibit C) that must include the following: Criminal background check for places of residence since age 16. Verification that the Student is not on the Sex Offender Registry for places of residence since age 16. Verification that the Student is not prohibited from participating in Federal healthcare programs. Notification to each Student that he/she must report to School any arrests and/or criminal charges or convictions filed subsequent to completion of the criminal background check. School further agrees to notify MUSC within 3 days of learning of such charges or convictions. Costs of such background checks are not the responsibility of MUSC. Criminal background checks may be conducted by an agency of the School’s choosing. School shall report adverse findings to the MUSC’s Human Resources Department prior to the start of the clinical rotation. The MUSC may, at its sole discretion, refuse to allow any student to participate in the Program based upon a review of the student’s background check. Health immunization record in accordance with the requirements for Visiting Students located at http://academicdepartments.musc.edu/esl/studenthe alth/student_resources/forms.html.

Student must maintain health insurance. Medicorp Health System (includes USA Faculty: Complete the Documentation of Mary Washington Healthcare) Compliance.

Fredericksburg, Virginia USA Faculty and Student POI: Lila Pugh, Staffing Specialist, Human Resources, [email protected], (540) 741-1694

MedStar Franklin Square Medical Nursing Faculty and Student: Must provide curriculum to Agency. Read and Complete Exhibits B-D (to Center include health screening requirements), Rosedale, Maryland Attachment B (Certificate of Student Requirements must be provided to agency within 30 days prior to beginning clinicals . Criminal background check and Drug Test must be done within twelve (12) months prior to start of clinicals. Students must maintain adequate

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered health insurance. Faculty will provide agency with the names of students forty-fine (45) days prior to their arrival. MedStar Georgetown University MSN, DNP The following items must be completed prior to student beginning clinicals: Faculty provides syllabus Hospital to CON contract office as Attachment A, Dean must Washington, D.C. sign Attachment B, and student signs Attachment D. MedStar St. Mary’s Hospital Nursing USA/Faculty: Complete attachment B and see attachment C. Provide curriculum requirements, Leonardtown, Maryland course descriptions and objectives for the clinical experience. Provide name(s) of students who will be on site during each semester at least 30 days prior to arrival. The faculty supervisor will be a faculty member of University who is certified, registered or licensed in the specialty of the student(s) assigned to the clinical field work experience.

Student: Must complete attachments D provided to Agency at least 30 days prior to beginning of experience. Must maintain adequate health insurance and provide Agency with evidence of such coverage at least 30 days prior to clinical experience. A 9 panel-non DOT drug test must be performed within 12 months prior to start of student’s clinical experience. Memorial Health Care System, Inc. MSN, DNP USA/Faculty: Submit annual report (if students within your specialty utilized this agreement) to indicates Chattanooga, Tennessee the extent to which the objectives of the course have Renewal in process-set to expire been obtained.

8/31/2018 Student: Must have Attachment B (Supervising Physician Agreement) completed. Complete Attachment C and D. Must have an annual TB screening, including chest x-ray if applicable. Must have OSHA approved training and education prior to clinical experience. Memorial Health System ( to include: USA/Faculty: Must provide evidence that student has Memorial Medical Center, the Abraham met the following requirements: CPR certification and proof of immunizations for Hepatitis B Lincoln Memorial Hospital, mental Health (vaccination), Measles, Mumps, and Rubella Centers of Central Illinois, Memorial Home vaccination; TB testing; and Varicella vaccine or Services, NFP, Memorial Home Services of history of Varicella. Central Illinois, Memorial Physician Student: Complete Facility's annual safety Services, The Passavant Memorial Area community based learning (CBLs), including, but not Hospital Association) limited to, OSHA Compliance for Prevention of Transmission of Bloodborne Pathogens and Springfield, Illinois Tuberculosis.

Memorial Healthcare Group, MSN, DNP USA/Faculty: Must complete Exhibits C-D. Students: Must complete Exhibits A-B. Inc./dba Memorial Hospital Jacksonville, Florida Drug and Alcohol Testing Please note: To ensure the accuracy and fairness of the testing program, all collection and testing will be conducted pursuant to guidelines established by the Medical Review Officers of the testing facility and, if applicable, in accordance with Substance Abuse and Mental Health Services Administration (SAMHSA) guidelines; a confirmatory test; the opportunity for a split sample; review by an MRO, including the opportunity for employees or students who test positive to provide a legitimate medical

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered explanation, such as a physician's prescription, for the positive result; and a documented chain of custody. Memorial Hermann Greater Heights MSN, DNP Students must complete Exhibit B prior to beginning clinicals. Please contact Keyla Robinson Hospital (previously Northwest) [email protected] for Houston, Texas information on student documentation that is required prior to any students beginning their clinical rotation.

Memorial Hermann Katy Hospital Nursing, RN-BSN, Student must complete Exhibit B. MSN, DNP Katy, Texas Memorial Hermann Medical Group MSN, DNP MSN and DNP Students Onboarding- http://texasnrc.org/Regions/Houston-Galveston/MH- Houston, Texas Pre-Clinical-Documents USA/Faculty: Please contact Dr. Lori Hull-Grommesh 713-515-4101 for student placement. Students: Must complete Exhibit B-HIPAA Form. Memorial Hermann Memorial City Nursing Students must complete Exhibit B. MSN, DNP Medical Center Houston, Texas Memorial Hermann Southwest MSN, DNP Please see the Agency’s onboarding process. Regulatory Compliance. Student will have (1) had Houston, Texas the following immunizations: Hepatitis B, MMR, Varicella, Tdap (tetanus, diphtheria/acellular pertussis), and the appropriate seasonal immunization for influenza; (2) proof of negative TB infection; (3) negative hepatitis C status; (4) will have passed a criminal background check; and (5) is not a person listed as excluded in the Federal, Texas or SCHOOL’s state specific exclusion databases with respect to government-sponsored health benefit programs, and is not listed as an excluded party by the Federal System of Award Management. Student must complete Exhibit B. Memorial Hermann-Texas Medical RN-BSN, MSN, DNP IMPORTANT-PLEASE READ The Memorial Hermann Privacy Office has noted Center and Children’s Memorial that students are transmitting identifiable patient Hermann Hospital information to their personal E-mail accounts. Houston, Texas This practice is against Memorial Hermann Policy, this practice will no longer be allowed to continue. If such actions continue, the student could lose their access to the Memorial Hermann electronic medical record. If the student needs the clinical information per class requirements, they must first redact all patient identifiers, i.e., names, date of birth, MRN/account #, address, phone number, names of relatives, etc., any name, date or number that could identify the patient. They may then use the information as needed for their class requirements.

Students please see Mary Margaret Evans@ site for required paperwork prior to clinicals. Also Student Faculty please note requirements in attachments folder. Students must complete HIPPA form. Memorial Hospital at Gulfport BSN, RN-BSN, MSN, USA/Faculty: Send name and schedule of students DNP to the Professional Development Department prior to Gulfport, Mississippi the beginning of clinical. (For BSN Students: Provide Hospital with curriculum vitae, evidence of appropriate licensure, and any other pertinent

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered (Any Memorial physician falls under information regarding faculty member(s) responsible for supervising students during the Clinical the same affiliation agreement as Education Program or A faculty representative from the hospital). the Educational Facility must be accessible by telephone. The Hospital department or clinical area will be notified in advance that the faculty member will not be present on the Hospital campus and how a faculty representative can be contacted. A Hospital employee will be designated to supervise the student in the Hospital department or clinical area).

Students: Must have current CPR card issued within the last 12 months. Must have Fit test and provide documentation or they will not be assigned known tuberculosis patients during the course of the Clinical Education Program.

Memorial Hospital University MSN, DNP Faculty please complete Exhibit B (Faculty Agreement) and Exhibit G (Verification of Student Medical Center Information) Student must complete attachments C Savannah, Georgia through F. Mercy Clinic Communities, Inc. NP Contact: Nancy [email protected]

Oklahoma City, Oklahoma USA/Faculty: Prior to beginning of clinicals the following information must be provided to the agency, student name, schedules and activities to be carried out in the clinical area, theory and clinical objectives, faculty's name, address, office and cell numbers, information on physical and educational requirements per agency policy.

Student: Must attend orientation provided by agency. Mercy Hospital Fort Smith MSN and DNP Upon request by Mercy, provide Mercy with each Student’s full name and identification (copy of Communities and Mercy Clinic Fort government-issued identification), license(s), health Smith Communities status reports, vaccination, and certification Fort Smith, Arkansas requirements as required by law and Mercy policy. Provide verification of a criminal background check for each Student prior to that Student’s participation in Clinical Experience as required by Mercy.

Students: Obtain and maintain health insurance. Mercy Health Oklahoma Nurse Practitioner Student must obtain and maintain health insurance Only Securing Preceptors Communities (covers: Mercy Clinic If a student needs to find a preceptor at Mercy with Oklahoma Communities, Inc., Mercy whom to rotate, please have them contact Janene Hospital OKC, Mercy Hospital Ada, Mercy Stewart either by phone (405-936-5813) or email Hospital Ardmore, Mercy Hospital El Reno, ([email protected]). Janene’s team will Mercy Hospital Healdton, Mercy Hospital locate a preceptor and notify the Medical Staff Kingfisher, Mercy Hospital Logan County, Services Department with the student’s name, email Mercy Hospital Tishomingo, Mercy Hospital address, school, preceptor and beginning/end dates of rotation. Watonga) Oklahoma City, Oklahoma Processing Student Rotation Paperwork The Medical Staff Services Department (MSS) will then email a rotation packet to the student to complete and return. This packet can be completed electronically in its entirety. Upon receipt of the packet, MSS will process it to ensure accuracy. Once the packet is complete, MSS will email the student notifying them of their clearance to rotate

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered and attach a security/badge form. The preceptor will be copied on the clearance email. Please note due to the number of students and the time involved to process the paperwork, MSS requires a minimum of 30 days notification for a rotation. Keasha Ayars is your main contact in the Medical Staff Services Department, however, there may be others that will assist Keasha when necessary. Keasha’s contact information is [email protected] , 405-752-3891.

Mercy Health Saint Mary’s, Nursing USA/Faculty: Must notify agency’s HR Department Nurse Practitioner (Taylor Haubenstricker - Mercy Health Physician Partners taylorhaubenstricker@mercyhealth.com)Julie Hill Grand Rapids, Michigan Ilbrink- [email protected]) at least 30 days prior to the date it desires to establish an education al experience to include dates and times. Students: Student must provide evidence of such to Group and Hospital prior to placement at a Group or Hospital facility. Such background check shall include fingerprinting pursuant to Group and Hospital policy and/or Michigan law. Institution will advise Students any felony conviction with the previous five years, and certain other convictions regardless of the length of time since conviction, would preclude a Student from being accepted for placement at a Group or Hospital facility and that other situations will be considered on a case-by-case basis, taking into account risks to patients, employees, Group and the Hospital. Must have documented OSHA and HIPAA training. Tuberculin skin test must be completed not more than one year prior to start date of clinical experience. Tuberculin Assessment Form must be completed if previous TB test was positive. If born before January 1, 1957 must have documentation of measles, mumps and rubella titers showing immunity. If non-immune, two MMR vaccinations. Attestation of having had the chicken pox or varicella titer as showing immunity. Must provide Agency with evidence of completion of Student Requirements as defined within 48 business hours of their request. Mercy Health-Springfield Nursing Student must obtain and maintain health Communities insurance. Springfield, Missouri Mercy Health Lourdes Hospital, LLC BSN, MSM DNP USA/Faculty: Provide to Agency student liaison with a list of students at least one week prior to the and Mercy Health Physicians clinical experience. Provide students with fire safety, Kentucky, LLC blood borne pathogens, and universal precautions in Paducah, Kentucky compliance with OSHA. Note: The Agency has a CRP (Corporate Responsibility Program) that promotes prevention, detection and resolution of instances of misconduct. USA shall immediately notify Agency’s Corporate Responsibility Officer of any violation of any applicable law or regulation of USA students or faculty become aware.

Student: See Attachment A and A-1, and complete A-2, see the policies and procedures at http://www.usccb.org/bishops/directives.shtml. Must

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered have physical examination showing they are free of communicable diseases, to include TB tests and required vaccinations. Must complete the Agency’s in-service on HIPAA which will be part of the student’s orientation process. Mercy Health Cincinnati LLC Students must read and sign Attachment A (Administrative Confidentiality Policy). Cincinnati, Ohio Mercy Health System of Northwest MSN The deadline for this year to receive proof of flu vaccine is November 15th. If we haven’t received Arkansas your immunization documents by November 15, we Rogers, Arkansas will be required to remove student access and the student will not be able to complete a rotation with Mercy.

See instructions for the 2017 requirement for “ready set” flu vaccine registration.

USA/Faculty: Provide upon request names, health status reports, and other pertinent information of each student to be assigned to clinicals. Provide training for Students in the HIPPA Regulations in the OSHA Blood-Borne- Pathogens regulations. Hazard Communication. Fire and Tornado and Emergency Preparedness. School and Facility shall arrange and provide orientation of Students concerning the Facility's policies, rules, and regulations. Agency contact: Nancy King, Executive Director of Inpatient Services 479-338-2380 [email protected].

Students: Should obtain and maintain health insurance. Must provide documentation of criminal background check.

Mercy Health System RN-BSN, MSN, DNP USA/Faculty: Notify Stephanie Walton, Education Coordinator [email protected] prior to student’s Janesville, Wisconsin clinicals. Provide copy of performance objectives for clinicals. Provide documentation of students training in blood and body fluid universal precautions to agency.

Students: Must complete exhibits A & B. Must have received training in blood and body fluid universal precautions consistent with US Centers for Disease Control. Must be vaccinated for influenza by November 15th. Mercy Hospital-Ardmore NP Faculty must send following information to agency prior to beginning of clinicals: Student name, Ardmore, Oklahoma Schedules and activities to be carried out in the clinical area throughout the experience, theory and clinical objectives, faculty's name and contact information. Agency contact: Melinda Sharum- [email protected] Mercy Health Southwest MSN, DNP, NP’s Provide upon request by Mercy, provide Mercy with each Student’s and, as applicable, each on-site Missouri/Kansas Communities Faculty member’s full name and identification (copy Covers Mercy Hospital-Joplin, Fort of government-issued identification), license(s), Scott, Joplin Clinic, Columbus, health status reports, vaccination, and certification requirements as required by law and Mercy policy. Carthage School shall further obtain and provide verification of Joplin, Missouri a criminal background check for each Student prior to that Student’s participation in a Practical Experience. If adverse information is obtained from

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered the criminal background check, School shall provide the information to Mercy after obtaining an authorization and release from the Student. Mercy may disqualify any such Student from participation with Mercy. If such authorization and release are not given by the Student, the Student shall be disqualified from participation in the Practical Experience. It is the School’s responsibility to ensure that any applicable drug screens have been completed and that Students with unacceptable results will not participate in Practical Experience at Mercy. Mercy LIFE of Alabama Undergraduate and Graduate Nursing Mobile, Alabama Mercy Medical Center MSN, DNP Exhibit A must be completed and signed by student. Des Moines, Iowa Mercy Medical Center Dubuque and Undergraduate and Students: Complete the following health Graduate Nursing requirements; Dyersville 2-step Tb skin testing or TB Quantiferon Gold blood Dubuque, Iowa testing unless previous history of positive reactor. Signs & symptoms screening for tuberculosis. Chest x-ray if indicated. Positive history of Chickenpox or a Varicella titer or proof of immunization. MMR x 2 or Negative titer for rubeola, rubella and mumps Review of immunization history, to include Hepatitis B for those students that the potential of being exposed to blood borne pathogens. Evidence, as required by Mercy Medical Center Hospital policy, that student(s) have received the annual vaccination against influenza, at their own expense, as currently required by Hospital policy and procedure relative to influenza vaccination, and as may be modified from time to time at sole discretion of Mercy Medical Center.

Abuse Background Check - student must have an Iowa child and dependent adult abuse registry check prior to placement at a Hospital facility. If the student has any prior convictions or current charges, the Institution will notify Hospital prior to, or during, placement at Hospital facility. Mercy St. Vincent Medical Center Exhibit A must be completed prior to beginning clinicals. Toledo, Ohio Meridian Behavioral Healthcare, Inc. Undergraduate and Graduate Nursing Live Oak, Florida Students Merit Health Central Nursing USA/Faculty: See Addenda 1&2.

Jackson, Mississippi Student: Complete Addenda 4,5, and 7. Renewal in process-set to expire 10/31/2018 Merit Health Natchez (to include Natchez Nurse Practitioner USA/Faculty: See Addenda 1. Clinic Company with Dr. Bhandari) Student: Complete Addenda 4,5, and 7. Natchez, Mississippi

Merit Health River Region Nurse Practitioner USA/Faculty: See Addenda 1-2 for duties that Students can/cannot be performed. Vicksburg, Mississippi

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered

Students: Must complete Addenda 4-6. Must have passed a background check within 12 months preceding Student’s provision of Patient Care Services. Must have passed a substance test in the 12 months preceding placement at the facility. Student must have health insurance while in clinical at Facility.

a negative TB skin test within the past year or, in the event of a positive TB skin test, a chest x-ray within the past three (3) years; OR provide evidence of no TB disease per negative result of interferon-gamma release assay blood test (T-Spot or Quantiferon Gold) within twelve (12) months of student activity at facility; (b) a completed series of Hepatitis-B vaccine, having begun the series, or informed refusal of the vaccine; and (c) any other appropriate immunizations requested by Facility. Merit Health Wesley Medical Center BSN, RN-BSN, MSN, “Student Agreement Only”-Students should DNP Hattiesburg, Mississippi complete a Term Sheet from the agency NOW includes FNP students. Agency contact Terry Trigg. Tel: (601) 268-8058. Merit Health Woman’s Hospital Nursing Student: Must complete Addenda 4, 5, and 7. Must have a negative TB skin test within the past year or, Flowood, Mississippi in the event of a positive TB skin test, a chest x-ray within the past three (3) years; OR provide evidence of no TB disease per negative result of interferon- gamma release assay blood test (T-Spot or Quantiferon Gold) within twelve (12) months of student activity at facility ; (b) a completed series of Hepatitis-B vaccine, having begun the series, or informed refusal of the vaccine; and (c) any other appropriate immunizations requested by Facility. Must have health insurance. Meriter-Unity Point Health Faculty and Students please see exhibit 1 for agency requirements per the addendum. Madison, Wisconsin USA Faculty must notify Meriter Hospital Medical Affairs Health Services and the Family Psychiatric Mental Health Practitioner in advance with participating student names and affiliation dates. Students must check in with Medical Affairs for a 10- minute orientation on the first day, or prior to, the start of clinical rotation. Student must provide documentation of influenza vaccination. State of Wisconsin requires evaluation of TB status annually. Student must have Caregiver Background Check. USA must certify in writing to agency that no student has any offenses on the Offenses List (Appendix III of the Wisconsin Caregiver Program Manual). USA will provide Agency with a letter that includes each Student’s name and ss# and listing any findings of misconduct found during the Caregiver Background Check. Methodist Health System (to 10/17/2016 No Nurse Faculty please see Exhibits A&B. Students must sign Practitioners at this Exhibit C. include: Methodist Dallas Medical time. Center, Methodist Charlton Medical MSN and DNP Center, Methodist Mansfield Medical Center, and Methodist Richardson Medical Center

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Richardson, Texas

ON HOLD UNTIL FURTHER

NOTICE-DO NOT APPROACH Nursing Students must sign Exhibit A (Hepatitis Methodist LeBonheur Healthcare Statement) prior to beginning clinicals. (covers: University, Germantown, Students must show documentation of flu North, South, Olive Branch, and Le vaccine. As of January 1, 2013-Students must have a background check and 10- Bonheur Children’s Hospital, and panel drug screen completed through many clinics) either Verified Credentials or Certified Memphis, Tennessee Background. No other vendor will be accepted.

Providing documentation of negative criminal background check for each student (within twelve (12) months of matriculation into the academic program), including without limitation a check in Tennessee, and if Tennessee is not the state of residence for the student(s), the state of residence of the student(s). The background check shall consist of the following:

i. the state’s law enforcement department; ii. the state’s family services department; iii. the Office of Inspector General’s List of excluded individuals; iv. the relevant state(s) licensing board(s) where applicable. Providing evidence of negative 10 panel drug screen from an independent provider, within thirty (30) days prior to entrance into the academic program. Failure of drug screen testing will disqualify a student from performing clinical rotations at Methodist Le Bonheur Healthcare facilities.

MHM Correctional Services, Inc. Nursing Programs Student: Must maintain health insurance during the clinical experience. May be required to have a Atlanta, Georgia physical examination. *ONLY for Alabama and Georgia sites. MHMR of Tarrant County RN-BSN, MSN, and Students must have had tuberculin skin test within DNP the past 12 months or documentation as a previous Fort Worth, Texas positive reactor or a chest x-ray takin within the past 12 months. Midland Memorial Hospital Undergraduate and USA/Faculty: All requirements listed on Exhibit B Graduate Nursing must be completed. at least four weeks prior to the Midland, Texas Students beginning of each clinical experience.

Prior to the beginning date of each Clinical Education Program, Institution shall provide the students participating in the Program the following information that applies to this Agreement:

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered (a) A description of the Program’s curriculum and required assignments for successfully completing the Clinical Education Program. (b) An explanation that the student shall not be deemed an employee of the Training Facility for purposes of compensation, fringe benefits, worker’s compensation, unemployment compensation, minimum wage laws, income tax withholding, Social Security, general liability insurance, or malpractice/professional liability coverage. (c) An explanation of the rules of professional conduct to which the student must adhere as a student participating in the Clinical Education Program, including confidentiality of patient information. (d) The students’ obligation to comply with Institution’s and the Training Facility’s rules and regulations while training at the Training Facility. (e) An explanation of the health and safety standards set by the Occupational Safety and Health Administration (OSHA) and other applicable law. (f) The students’ responsibility to seek out and receive health care at the time of exposure to infectious agents, i.e. blood borne pathogens, tuberculosis and others, while on duty at the Training Facility and provide any copies of medical records of these health care services to the Training Facility. Institution shall reimburse Training Facility for reasonable costs incurred for testing, including follow-up testing. (g) The students’ obligation to obtain prior written approval from the Institution and Training Facility before publishing any material relating to the Clinical Education Program. Minden Medical Center MSN, DNP Student must contact Allison Ouzts at 318-371-3266 to coordinate clinicals. Each student who will be or is Minden, Louisiana in facility from October 1st to April 1st to show proof of Flu Vaccine. If the student is unable to take the FLU vaccine due to medical reasons, Religious beliefs, or chooses to decline they must sign a declination and submit that record to the hospital.

All students who do not comply with the mandatory flu vaccine must wear an N-95 duck bill mask at all times and in all locations other than the cafeteria or private offices while in Minden Medical Center. Please have students sign an acknowledgement of this fact if they decline the vaccination. Minden Physician Practices, LLC MSN, DNP USA/Faculty: Provide recommended objectives of the fieldwork experience and provide objectives to d/b/a The Womens Clinic facility. If requested USA Faculty shall make periodic Minden, Louisiana visits to the facility for the purpose of discussing the clinical experience of the students. Provide student information to facility at least one month in advance to facility. Notify facility of any student absences.

Student: Obtain and maintain health insurance coverage. Upon request of facility, student must sign a confidentiality agreement.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Ministry Health Care, Inc. (both USA FACULTY PLEASE SEE INFORMATION FOR IN LIEU OF LON INSTRUCTIONS. Ministry Health Care and Affinity Health sites are covered) Weston, Wisconsin Faculty Licensure Required RN & APRN. CNS and Executive Nursing require RN Licensure.

USA/Faculty: Submit a description of syllabus requirements and other clinical objective expectations to facility. Also, provide a letter indicating the names, social security numbers of student. Complete the Background Information Disclosure Form (BID), available from agency. Agency Education Manager, Brant Bergeron-715- 343-3371, [email protected]. Student must have health care worker safety education according to OSHA standards.

Student: Must have a background check in accordance with the Wisconsin Caregiver Background Check Law.

Minnesota State Community and USA/Faculty: Send the student information to the facility. (Facility contact: Jennifer Jacobson, Dean of Technical College Health, [email protected] Moorhead, Minnesota 6817).

Student: Must maintain health insurance coverage.

Minute Clinic, LLC Masters, Post Please see the Minute Clinic Student Precepting Masters, DNP Process Sheet. Woonsocket, Rhode Island Exhibits A and B must be completed. Provide (Corporate Ofc). preceptor with course outlines, objectives, student rotation assignments and student evaluations forms.

The McDowell Hospital, Inc. Only covers the Questions for onboarding and orientation processes: Mission Education Services (Mission Hospital) following programs MSN-Dual Role 828-213-0779 Asheville, North Carolina MSN-FNP [email protected]

USA/Faculty: Submit roster of students who will participate in the clinical experience at Facility. Students-May be required to participate in any required orientation process developed by the Facility. Mission Hospital, Inc. and Carolina ONLY the following Questions for onboarding and orientation processes: programs are covered Mission Education Services Mountain Emergency Medicine, PA. DNP-Family Psych 828-213-0779 MSN-CNS Asheville, North Carolina MSN-Dual Role [email protected] MSN CNS Adult Geron MSN Nursing Informatics USA/Faculty: Submit roster of students who will participate in the clinical experience at Facility. Students-May be required to participate in any required orientation process developed by the Facility. Mission Hospital, Inc., Mission DNP Family Questions for onboarding and orientation processes: Psychiatric NP Mission Education Services Medical Associates, Inc., Carolina 828-213-0779 Mountain Emergency Medicine, PA, MSN [email protected] Asheville Pulmonary Associates, PA ~Clinical Nurse Specialist USA/Faculty: Submit roster of students who will (Must be utilizing all 4 agency’s participate in the clinical experience at Facility. for this agreement)

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Asheville, North Carolina ~Dual Role (Family Students-May be required to participate in any /Adult-Geron-Acute required orientation process developed by the Care Facility. ~ Adult Gerontology Clinical Nurse Specialist DNP-Dual Role (FNP/Adult Geron Acute NP) Mission Medical Associates (All MSN-FNP USA/Faculty: Submit roster of students who will MSN-Pediatric participate in the clinical experience at Facility. Sites) Primary Care NP Students-May be required to participate in any Asheville, North Carolina required orientation process developed by the Facility.

[email protected] 828-213-0779 Mississippi Emergency Physicians Nurse Practitioner Students (Schumacher Group) only valid at Merit Health Natchez Natchez, Mississippi Renewal in process-set to expire 11/1/2018 Mississippi State Department of Nursing Faculty please arrange for clinical locations Health and times with the county coordinating nurse/and or the district chief nurse. County Jackson, Mississippi health department contact information can be found on the MSDH website at http://msdh.ms.gov under the location tab. District chief nurse list is on the agency attachments list. Mississippi State Hospital Undergraduate and USA/Faculty: Submit to Agency at least 3 Whitfield, Mississippi Graduate Students weeks prior to the beginning of each clinical experience, a schedule indicating the number and names of students. Mobile County Health Department BSN, RN-BSN, MSN, DNP Mobile, Alabama Mobile County Public Schools Undergraduate and Graduate Students Mobile, Alabama Mobile Ob-Gyn, P.C. BSN, RN-BSN, MSN, DNP Mobile, Alabama

Moffitt Cancer Center RN-BSN, BSN, RN- RN-BSN, BSN, RN-MSN, and DNP programs. MSN, DNP Schedule 4.8 Screenings and Vaccination Tampa, Florida Schedule 4.9 Student Letter Agreement, must be completed by student. Moncrief Army Community Hospital FAMILY Family Psychiatric Nurse Practitioner students. PSYCHIATRIC NP Students must complete Student Packet (in Fort Jackson, South Carolina attachments folder). Once completed students must contact the Hospital Education Department 803-751- 2488. Monroe Manor Health and Undergraduate and Rehabilitation Center (Ball Graduate Nursing Healthcare Center) Monroeville, Alabama

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered MonteVista Hospital Undergraduate and Graduate Nursing Las Vegas, Nevada Montrose Memorial Hospital Undergraduate and Graduate Nursing Montrose, Colorado Students Morehouse General Hospital Undergraduate and Graduate Nursing (covers Morehouse General Students Hospital Physician Clinics) Bastrop, Louisiana Morrow County Hospital Undergraduate and Graduate Nursing Mount Gilead, Ohio Students Mosaic Community Services Undergraduate Timonium, Maryland and Graduate Nursing Cone Health *Cone Health *Cone Health Employees Only* Employees Only* USA/Faculty: Notify Agency of planned schedule Greensboro, North Carolina Graduate Nursing of student assignment, including name of *Cone Health Employees Only* Programs student, level of academic preparation, length and dates of clinical. Contact for USA Faculty Only: Sandy Coble- [email protected]

Mount Carmel Health and Mount Nursing Students Students: Carmel Medical Group *Before beginning the program, each participating student from the School must Columbus, Ohio present to MCHS and/or MCMG evidence of professional liability insurance in the amount of $1,000,000 per occurrence and $3,000,000 in the aggregate and general liability insurance in the amount of $1,000,000 per occurrence and $5,000,000 in the aggregate. Proof of said insurance must be presented to MCHS and/or MCMG and School (USA College of Nursing’s Clinical Affairs Department) before a participating student may begin his or her professional experience. Said insurance may not be canceled without thirty (30) days' notice to MCHS and/or MCMG. In the event professional liability insurance covering a participating student is canceled, said student shall no longer be eligible to participate in the professional experience.

a passing score of 80% on all MCHS and/or MCMG testing; a current healthcare provider CPR card from American Red Cross or American Heart Association, as applicable; a negative 5-panel drug screen; and a felony and misdemeanor criminal background check showing no findings Such background checks shall include fingerprinting pursuant to Ohio law. If the Student has any prior

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered convictions or current charges for any state or federal offenses, other than minor traffic violations, the School will notify MCHS and/or MCMG prior to, or during, placement at MCHS and/or MCMG facility. However, any felony conviction within the previous five years, and certain other convictions regardless of the length of time since conviction, would preclude a Student form being accepted. Other situations will be considered on a case-by-case basis, taking into account risks to patients, employees, and MCHS and/or MCMG. Mountain View Pediatrics Undergraduate and Graduate Students Flagstaff, Arizona MultiCare Health System (to include: Nursing Students USA/Faculty: Please refer to Schedule 1 if MutliCare Health System, MutliCare applicable. Student: Complete Exhibit A. Allenmore Hospital, MultiCare Auburn Students agree to meet all the requirements of MHS’ Medical Center, MultiCare Good Samaritan, Non-Employed Staff On/Off Boarding policy (copies Mulitcare Tacoma General Hospital, of which are available upon request) including those Multicare Mary Bridge Children’s Hospital, immunization and other requirements outlined in the MultiCare Covington Medical Center, policy and its exhibits. Students agree to abide by MultiCare Gig Harbor Medical Park, the Standards for Business Conduct set forth by Multicare Deaconess Hospital, MultiCare MHS which can be found on the internet at Valley Hospital) http://www.multicare.org/our-mission-values Tacoma, Washington MultiCare-Rockwood Clinic RN-BSN, MSN, and Agency Contact-Katie Rivard, Student Services DNP Coordinator [email protected] Spokane, Washington USA/Faculty: Please see Addenda 1-3. Students must complete Addenda 4-6. See Exhibit A for Internship Health Requirements.

A completed series of Hepatitis-B vaccine, having begun the series, or informed refusal of the vaccine;

Agency Name Programs Agency Requirements Covered Nathan Adelson Hospice USA must submit to agency 3 weeks prior to Las Vegas, Nevada the beginning of clinical rotation, a schedule indicating number and names of students participating and the name of their supervising faculty. National Jewish Health BSN, RN-BSN, MSN, See Exhibit A-Immunization requirements per the DNP agreement. Denver, Colorado

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered

Nationwide Children’s Hospital MSN, DNP Student: Complete Exhibits A-C. Columbus, Ohio Navajo Area Indian Health Service RN-BSN, MSN, DNP Student: Complete Exhibit A. Must pass a criminal (to include: Gallup Indian Medical Center, history background check, pursuant to the Indian Tohatchi Health Center, Northern Navajo Medical Child Protection and Family Violence Prevention Center, Four Corners Regional Health Center, Act, to include fingerprint check. Crownpoint Health Care Facility, Thoreau Health Clinic, Pueblo Pintado health Center, Chinle Comprehensive Healthcare,Tsaile Health, Pinon Health, Kayenta health Center, Inscription House Health Center) Arizona and New Mexico Naval Health Clinic Cherry Point Nurse Practitioner Marine Corp Air Station Cherry Point, North Carolina Naval Health Clinic-Goose Creek NP Student must complete Trainee Agreement. Charleston, South Carolina Renewal in process-set to expire 12//2018 Naval Health Clinic New England Nursing and Nurse Practitioner Students Naval Branch Health Clinic Groton Groton, Connecticut Naval Hospital (to include Its Branch RN-BSN, MSN, DNP Contract includes: Allied Health students Students are required to complete a confidentiality Clinics, i.e., Whiting Field Clinic) statement prior to clinical experience (See faculty) Pensacola, Florida Naval Hospital, Camp Lejeune RN-BSN, MSN, DNP Students must complete trainee addendum. Camp Lejeune, North Carolina NCH Healthcare (Naples NP USA Faculty: Shall confirm in writing that each student has on file a record of completed Community Hospital) immunizations and CPR as appropriate. Shall Naples, Florida provide Agency with current curriculum. Renewal in process-set to expire Student: An administrative fee of $150.00 per 7/31/2018 student, payable to NCH Healthcare System, Inc., will be charged and is due from the student two weeks prior to the start of clinical placement. The fee should be sent to the attention of Carol Johnson, Department of Education, NCH Healthcare System.

Nebraska Methodist Hospital MSN, DNP Omaha, Nebraska Nemours Foundation (This is a global Nursing USA/Faculty: Notify agency not less than 6 weeks agreement should cover all Nemours) prior to clinical placement, of its planned schedule of assignment, including names of student and level of Jacksonville, Florida academic and clinical preparation. Upon request provide the student’s academic and clinical history, and a copy of their CV. Student: Agency requires confirmation of citizenship or legal status to be in the United States, and may require an interview, prior to acceptance in the clinical rotation.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Neonatal Specialists, LTD (at NNP ONLY In conjunction with the Tucson Medical Center agreement. Tucson Medical Center) Tucson, Arizona USA/Faculty: Notify Affiliate through the Program Coordinator the Name of Student, Schedule of assignment, level of training, length and dates of the clinical experience. New Hanover Regional Medical Nursing Programs USA/Faculty: The start and ending date of Center each experience shall be agreed upon at least one month prior to the beginning of said Wilmington, North Carolina experience. Each assignment will not exceed a 1:10 instructor/student ratio. At least 10 days prior to the beginning of each experience please provide to the Director the names of students and faculty.

Students: Must sign a confidentiality agreement provided by the agency. To purchase an ID badge issued by the Hospital (“ID Badge”) for each participating Student and Faculty. The cost of an ID Badge, as well as any replacement cost in the event the ID Badge is lost or stolen, will be Fifteen Dollars ($15.00) which is subject to change from time to time at the sole discretion of the Hospital. Students and Faculty members must wear their ID Badge at all times while participating on site at the Hospital. Newberry County Memorial Hospital Undergraduate and Graduate Students Newberry, South Carolina NIH Clinical Center Undergraduate and USA/Faculty: Communicate with the Clinical Center Graduate (no Nurse Nursing Department (Diane Walsh, 301-326-7040- Bethesda, Maryland Practitioner students) [email protected].

Student must have personal medical/health insurance coverage during clinical experience at facility. Norman Regional Health System Nurse Practitioner USA/Faculty: Please send copies of the following to Students Only Provider Institution no less than two weeks prior to Norman, Oklahoma the commencement of the clinical assignment: Names of the relevant Students Relevant COLLEGE procedures and policies Evaluation procedures and forms Each Student’s proof of current immunization record Each Student’s proof of professional liability insurance.

Agency contact: Drea Murphy Coordinator, Physician Residency & Graduate Medical Education [email protected] Office (405) 307-5340

North Mississippi State Hospital NP Tupelo, Mississippi North Mississippi Medical Center- Nurse Practitioner USA/Faculty: Annual joint meeting to evaluate the Programs Only Clinical Education Program. Pontotoc

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Pontotoc, MS Student: Require each student to submit proof and be considered immune by providing the following: (1) Documentation of having received two live measles containing vaccinations after their first birthday, (2) documentation of initial two step and up to date TB skin test followed by annual testing, (3) documentation of three Hepatitis-B vaccinations or in process, (4) documentation of having received a tetanus containing vaccination within the past 5 years and a prior tetanus/diphtheria/pertussis (5) documentation of flu vaccine October-March or alternatively require student to sign a waiver and wear a mask when in a NMHS owned or operated facility. Medical contraindications to vaccines and positive TB skin test follow-up must be reviewed by NMMC Pontotoc Employee Health. Complete Health Sciences Advisory on Employment and Criminal Offenses (Exhibit A) and Healthcare Criminal History Background Affidavit (Exhibit B). Complete Student Agreement. Obtain and maintain health insurance during clinical experience. North Mississippi Medical Center- Nursing and Nurse USA/Faculty: Annual joint meeting to evaluate the Practitioner Programs Clinical Education Program. Tupelo Tupelo, Mississippi Student: Require each student to submit proof and be considered immune by providing the following: (1) Documentation of having received two live measles containing vaccinations after their first birthday, (2) documentation of initial two step and up to date TB skin test followed by annual testing, (3) documentation of three Hepatitis-B vaccinations or in process, (4) documentation of having received a tetanus containing vaccination within the past 5 years and a prior tetanus/diphtheria/pertussis (5) documentation of flu vaccine October-March or alternatively require student to sign a waiver and wear a mask when in a NMHS owned or operated facility. Medical contraindications to vaccines and positive TB skin test follow-up must be reviewed by NMMC Tupelo Employee Health. Complete Student Clinical Agreement Exhibit A, Health Sciences Advisory on Employment and Criminal Offenses Exhibit B and Healthcare Criminal History Background Affidavit. Obtain and maintain health insurance during clinical experience. North Mississippi Medical Clinics, Nurse Practitioner Students must complete and sign the attached Student Program Agreement, Health Advisory, and Inc. Background Affidavit prior to beginning clinicals. Tupelo, Mississippi Students must obtain and maintain personal and professional liability insurance with coverage and amounts determined by NMMCI. Students must not be an employee of NMMCI within the meaning of the Mississippi Workers' Compensation Law. North Oaks Health System (includes Students must notify agency education director Nicole Barnum (985-230-6594) prior to starting North Oaks Rehabilitation Hospital, clinicals. Must be in compliance with Louisiana State Primary Care-Independence, Board of Nursing. Only selected students may Magnolia OB/GYN) participate that have completed prerequisite portion of curriculum. USA CON must complete Exhibit 1 Hammond, Louisiana Pre-A

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Assignment Results Form prior to student beginning clinicals.

All students will be required to provide proof of Influenza vaccination on or before November 1, 2013. USA faculty must provide a roster of students participating in clinicals and attach proof of influenza vaccination. Students not in compliance with these guidelines will not be able to participate in clinical rotations after November 1st. North Okaloosa Medical Center Nurse Practitioner Students are required to participate in an hourly ONLY rounding lab before clinicals at facility. NP students Crestview, Florida only. Students must complete addenda 4-6. Negative TB skin test within the past year or, in the event of a positive TB skin test a chest x-ray within the past three years. OR provide evidence of no TB disease per negative result of interferon-gamma release assay blood test (T-Spot or Quantiferon Gold) within 12 months of clinical experience. Completed series of Hepatitis-B vaccine having begun the series. North Okaloosa Medical Center BSN, Nursing Students are required to participate in an hourly Admin, CNL, Nurse rounding lab before clinicals at facility. Students Crestview, Florida Exec. must complete addenda 4-6.

Northern Alabama Physicians, LLP Undergraduate and Graduate Traverse City, Michigan Northern Arizona Healthcare (to Students must check in with the education department at the facility and complete the student include: Flagstaff Medical Center, module prior to starting clinicals. Students may find Verde Valley Medical Center, and the module and paperwork on the facility’s website: Northern Arizona Homecare) www.nahealth.com/education. Once completed they can fax to 928-773-2430. Flagstaff, Arizona Northern California Medical Undergraduate and Graduate Nursing Associates, Inc. Santa Rosa, California Northport Medical Center (DCH BSN, RN-BSN, MSN, Hospital Authority) DNP Northport, Alabama Northridge Medical Center Undergraduate and Graduate Nursing Commerce, Georgia Students

Northside Hospital (Northside BSN, MSN, DNP NP Agreement is separate-Please see Exhibit

Hospital, Northside Hospital Forsyth A-sponsoring physician or sponsoring agency Nurse Practitioner- will need to complete. Also see Exhibit B and and Northside Hospital Cherokee) separate agreement C. Atlanta, Georgia Renewal in process-set to expire All others- 11/9/2018-RN, MSN, DNP USA/Faculty: See Exhibit C.

agreement. At time of enrollment in the program: student will need to have a physical exam (to include: PPD test or chest x-ray, hepatitis -B core antibody test, and Rubella and Measles test or documentation of immunization). Student to complete Exhibit B.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Northwest Emergency Physicians, Graduate Nursing USA must have an in place greement with Facility where clinical experience is taking place. LLC Knoxville, Tennessee

Northwest Florida Community Undergraduate and Graduate Students Hospital Chipley, Florida

Northwest Florida Emergency Nurse Practitioner Northwest Florida Emergency Students Physicians (Schumacher Group) Physicians (Schumacher Group) only only valid at Santa Rosa Medical valid at Santa Rosa Medical Center Center Florida Florida Renewal in process-set to expire 11/1/2018 Northwest Hospital & Medical Nursing Programs USA/Faculty: SEE EXHIBITS A&B Center Provide the following; Beginning dates and length of experience (to be Seattle, Washington mutually agreed upon at least one month before the beginning of the clinical education program); Number of students eligible to participate in the clinical education program; Specific days, hours and locations for the clinical education program; Specific learning objectives and performance expectations for students; Specific allocation of responsibilities for the faculty Liaison, clinical education Supervisor, and Preceptors, if any, referenced elsewhere in this Agreement; Deadlines and format for student progress reports and evaluation forms. Student: Must have health and accident insurance. Northwest Physicians, LLC-Benton Advanced Practice USA/Faculty: See Addendum 1. Nursing Must provide clinical coordinator contact information County Physician Services to facility. Keep on file a copy of the Student's Springdale, Arkansas completed addenda 4-6. This may be sent to the USA Clinical Affairs Department.

Student: Must complete addenda 4 & 5. Must have health insurance during their clinical experience at Facility.

Northwestern Memorial Hospital RN-BSN, MSN, DNP Student: Complete Exhibit A. Must provide proof of full health insurance. Background Check must be in Chicago, Illinois compliance with the Illinois Healthcare Workers Renewal in process-set to expire Background Check Act. 8/23/2018

Norton Healthcare/ Neonatal NP NP Students. Faculty must schedule/coordinate clinical experience Associates (Norton Kosair Children’s with facility at least 6 weeks in advance of clinicals. Hospital, Norton Suburban Hospital, Norton Audubon Hospital, Norton Hospital, and Norton Brownsboro Hospital)

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Louisville, Kentucky Norton Hospitals, Inc. (Norton Audubon Student: Must have negative drug screen within six Hospital, Norton Brownsboro Hospital, months of placement at Hospital. Norton Women’s & Kosair Children’s Hospital, Kosair Children’s Medical Center- Brownsboro, and Kosair Children’s Hospital) Lexington, Kentucky Novant Culpeper Medical Center Nursing For information on experiential learning opportunities and/or requirements, please email inquiries to: Culpeper, Virginia [email protected].

Novant Health Hospitals (Covers MSN, DNP Students must go to https://www.novanthealth.org/careers/student- ALL Novant facilities, including programs.aspx for a list of all requirements of clinics) participation, which includes all forms that the North Carolina student and faculty will need to complete and sign. Please follow all directions.

USA FACULTY-Please follow the guidelines for “In Triad Region: Forsyth Memorial Lieu of an LON”. Agency will not sign the LON. Hospital, Foundation Health Systems, Carolina Medicorp Enterprises, Forsyth Medical Group, Community General Health Partners, Medical Park Hospital.

Southern Piedmont Region: Presbyterian Orthopaedic Hospital, Presbyterian Medical Matthews, Presbyterian Hospital, Presbyterian Regional Healthcare, Presbyterian Hospital Huntersville, Prince William Medical Center

Agency Name Programs Agency Requirements Covered Obstetrix Medical Group of Graduate Nursing Colorado (Pediatrix) Colorado Springs, Colorado Agreement covers every practice in the Denver Colorado metro area. Ocala Health (Ocala Regional MSN, DNP USA/Faculty: Provide adequate documentation attesting to competency of each instructor. Complete Medical Center & West Marion Exhibit C-Attestation. Community Hospital)

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Ocala, Florida Student: Complete Exhibit A and B. Must pass medical examination acceptable to Hospital prior to experience. Ocala Health Primary Care, LLC \ USA/Faculty: Must complete Exhibit C-Attestation Statement and return to Agency Contact. Tracy d/b/a Family Care Specialist Pickover-352-629-7979- Ocala, Florida [email protected].

Student: Must complete Exhibits A & B. OCH Regional Medical Center BSN, RN-BSN, MSN, DNP Starkville, Mississippi

Ochsner Clinic Foundation Undergraduate and Exhibit A must be completed by student.-Statement Graduate Nursing of Responsibility and Confidentiality Statement prior New Orleans, Louisiana (covering to starting clinicals. See Mid-Level Application if Ochsner Community Hospital, Ochsner Medical applicable. Students must obtain and maintain health Center-Kenner, Ochsner St. Anne General insurance acceptable to hospital. Hospital, East Baton Rouge Medical Center, Baton Rouge and Ochsner Medical Center- Contact: Northshore and Ochsner Clinic Foundation- Saleha Mehr West Bank Campus) Program Coordinator/ Administrative Assistant (Includes all 32 regional clinics Slidell, System Nursing Professional Development Covington, etc.) 504-842-8796 [email protected] Ogden Clinic BSN, RN-BSN, MSN, Agency contact is Jolene Guarniere, HR Specialist & DNP Student Coordinator, Ogden Clinic (801) 475-3429 Ogden, Utah [email protected]

OhioHealth Corporation (to include: Please see updated documents for requirements and submission to facilities. Doctors Hospital, Dublin Methodist Hospital, Grady Memorial Hospital, Grant Medical Center, Marion Clinical Term Begins Application Window General Hospital, Riverside Methodist January-April Sept. 1 ̶ Oct. 1 May-July Feb. 1 ̶ March 1 Hospital) August-December April 1 ̶ May 1 Columbus, Ohio

USA/Faculty: Notify Facility at least seven (7) days prior to clinicals and again the day the clinical begins. Student: Must obtain health insurance coverage. Ohio State University Medical Students please request information about Ohio Board of Nursing Requirements(Attachment A) Center Columbus, Ohio Ohio State University- on behalf of Faculty members please see me regarding attachment A prior to student’s clinical experience The Arthur James Cancer Hospital and Richard J. Solove Research Institute Columbus, Ohio Okaloosa County Health Dept. BSN, RN-BSN, MSN, DNP Fort Walton Beach, Florida Oklahoma City Area Indian Health BSN, RN-BSN, MSN, DNP Service (covers, White Cloud Health Station, Haskell Indian Health Center, Claremore Indian Hospital, Pawnee Indian Health Center, Wewoka Indian Health Center, Clinton Indian Health Center, El Reno Indian Health Center,

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Watonga Indian Health Center, Lawton Indian Hospital, Anadarko Indian Health Center, Carnegie Indian Health Center) Oklahoma City, Oklahoma

Oklahoma Heart Hospital, Undergraduate and Oklahoma Heart Hospital South, Graduate Nursing Oklahoma Heart Hospital Physicians Oklahoma City, Oklahoma Oklahoma State Department of Nursing Students USA/Faculty: Please see the Instructions for requesting placement, along with the Regional Health Director Authorization Form. Oklahoma City, Oklahoma Students must complete HIPAA Training for Nursing Students. Please see clinical faculty for detailed instructions. Once the students complete the HIPAA Agreement covers ALL county health online training, they will be able to print out a departments. certificate. Prior to clinical experience, USA must provide Student’s name, schedule and activities to be carried out in the clinical, theory and objectives, faculty’s name and contact information. Agreement covers ALL county health departments. Opelousas General Health Undergraduate and Students see Agency’s Code of Conduct- must Graduate Nursing comply with the Hospital’s compliance program. System Must have background check as required by the Opelousas, Louisiana Louisiana licensure and to include the System for Award Management (SAM). All students shall provide the Hospital with verification of the following: Instruction on the principals of Infection Control and Isolation by Agency. Instruction on the Bloodborne Pathogens Law and the Needlestick Safety Act. Vaccination for Hepatitis B and can provide proof at any time or a signed declination for the Hepatitis Vaccine Current annual PPD and can provide this documentation at any time. Orange Park Medical Center RN-BSN, MSN, DNP USA Faculty cannot do site visits to this facility. Only. Student needs a 10 panel annual urine drug Orange Park, Florida screen. Renewal in process-set to Students Must go through My Clinical Exchange to request a clinical experience. expire 12/9/2018 Please contact USA’s Clinical Affairs Department at [email protected] USA Faculty: Must verify, complete, and sign the Student Affiliation Checklist. Oregon Health & Science Agency Education Contact: Bonnie Cox [email protected] 503-494-3698. University Portland Oregon Students: Must provide proof of up-to-date Renewal in process-set to immunizations, CPR certification and Bloodborne Pathogen training. Complete OHSU’s HIPAA expire 12/31/2018 Privacy Training prior to beginning Clinicas at OHSU. Provide OHSU with proof of having successfully passed criminal background screening and drug screening. Orlando Health, Inc. Clinical Nurse Specialist USA/Faculty: Please see Schedule D for a reference Program ONLY to student disqualification guidelines. Must provide a Orlando, Florida for Orlando Health list of students to Agency at least 10 days before the Employees start of each clinical experience.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Agency Employees ONLY

STUDENTS DO NOT APPROACH THIS SITE FOR ANY ROTATIONS. EITHER WITH A TWO PAGE OR REQUEST TO ESTABLISH. THEY WILL NOT ACCEPT. OU Medical Center Nursing USA Faculty: Provide a roster of the names of the Clinical Instructor and Students along with a rotation Oklahoma City, Oklahoma (OU schedule to the Human Resources Manager Chris Medical Center, The Children’s Patrick - [email protected] Hospital at OU Medical, and OU Students are required to submit flu vaccinations Medical Center Edmond) information and additional paperwork prior to clinicals to Steven Gifford via fax to (405) 271-7344. Students must review the orientation information online prior to beginning clinicals. (see website below) Faculty should contact Contract person at CON with any questions. Students must adhere to agency’s Flu Vaccine program –see attachment.

http://www.oumedicine.com/body.cfm?id=832 Please see Vonda Epperly at site for further orientation information prior to starting clinicals.

Students will be required to participate in drug/alcohol testing pursuant to Facility's policy for Drug and Alcohol Testing. Testing will be performed upon reasonable suspicion; after a reportable event; upon damage to Facility equipment or property; and after any "on the job" injury to another student, an employee, or a patient when Facility believes the acts or omissions of the student to be tested may possibly have caused or been partially responsible for the injury. Student must notify his/her School Faculty and Facility Preceptor whenever he/she is taking a prescribed or over- the-counter drug that they have been advised will impair job performance. Student must be aware that by entering the Facility property, each student consents to a search and/or inspection. Searches can be conducted of pockets, clothing, lockers, wallets, purses, briefcase, lunchboxes, backpacks, duffel bags, work stations, equipment, and other areas. OU Physicians Nursing Student must complete Attachment A, “Affiliation Confidentiality Agreement,” prior to beginning Oklahoma City, Oklahoma clinicals.

Our Lady of the Angels Hospital, Family NP USA Faculty contact Education Manager, to Dual Role coordinate clinicals for non NP Inc. FNP/AGACNP [email protected]. Bogalusa, Louisiana CNL For NP Students Exec Nurse Admin [email protected] Adult Geron Acute NP Student must complete Attachments 1-3.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Contact Clinical Affairs Complete Information Form to add additional Effective October 1, 2018 -- Orientation for each programs. month will be as follows:

· First full week of the month

o Monday @ 8:30a

o Friday @ 1:00p

· Third full week of the month

o Monday @ 8:30a Wednesday @ 8:30 a

Students must coordinate their orientation prior to clinical rotation during one of these scheduled times. Student will not be permitted in hospital or clinics without completing orientation. For more specific monthly orientation dates/times, have students call OLOAH, Education Department @ 985-730- 6771Complete Information Form

Our Lady of the Lake Ascension Students must complete Attachment 1 (Student Agreement), Attachment 2 (Confidentiality Community Hospital, Inc. d/b/a St. Agreement), and Attachment 3 (Statement of Elizabeth Hospital Responsibility) prior to beginning clinicals. Gonzales, Louisiana Agreement will be terminated Students must complete Attachment 1 (Student Agreement), Attachment 2 (Confidentiality on May 31, 2018. NO students Agreement), and Attachment 3 (Statement of will be allowed at this facility Responsibility) prior to beginning clinicals. after May 30th. Our Lady of the Lake Ascension Community Hospital, Inc. d/b/a St. Elizabeth Physicians Gonzales, Louisiana Our Lady of the Lake Assumption Community Hospital, Inc. Students must complete and sign Attacments 1-3

Nepoleonville, Louisiana Our Lady of the Lake Physician Please Note: When a preceptor is employed by the OLOL Physician Group and the student will Group, LLC be going into the OLOL Regional Medical Center Baton Rouge, Louisiana both the Letter of Notification (LON) for the Physician Group and the Medical Center should be signed by Julia Sigur. If preceptor is employed by the hospital and not the physicians group Lisa Loustalot will sign the LON.

Please see the checklist and forms to be completed by your students and submitted to me at least 3 weeks prior to an externship. List of LPG clinic locations with managers contact information for securing clinical experiences.

Students must complete Attachments 1-3 prior to beginning clinicals. USA Faculty please see procedure checklist, request form, practitioner letter, Orientation Packet. Facility needs to receive a list of

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered student’s names and rotation information along with the OLOL Physician Group’s requirements at least three weeks prior to the agreed upon start date of the rotation, send this information to Julia Sigur - [email protected] Please request all corresponding attachments from the contracts office. Our Lady of the Lake Regional Nursing Prior to contacting agency, students must have a background check, TB skin test, and a CURRENT Medical Center (within 1 semester) drug screen, and complete Baton Rouge, Louisiana Attachments 1-3. If using a non-OLOL employed physician or third level, the Revised Sponsoring Physician LetKyndall Jones ter must be signed prior to meeting with Students/faculty should contact Kyndall Jones ([email protected] Director for Nursing Research prior to beginning clinicals to ensure compliance with all requirements. Agency must receive electronic clinical objectives. Program Director must receive specific dates student will be in this facility. Agency will visually check RN licensure and current CPR prior to student beginning at this facility. To include PNP program. To include DNP program. Please Note: When a preceptor is employed by the OLOL Physician Group and the student will be going into the OLOL Regional Medical Center both the Letter of Notification (LON) for the Physician Group and the Medical Center should be signed by Julia Sigur. If preceptor is employed by the hospital and not the physicians group Lisa Loustalot will sign the LON.

Our Lady of Lourdes Regional

Medical Center Lafayette, Louisiana

Owensboro Health and Nursing USA Faculty Contact Clinical Affairs for Owensboro Medical Group verification of negative status of student’s utilizing this agreement on the Nurse Aide Owensboro, Kentucky Registry maintained by the Kentucky Board of Renewal in process-set to Nursing. USA will provide to Agency. expire 11/17/2018 Students: Must complete exhibits A&B. Students must complete an orientation to, and be in compliance with, standards of conduct, rules, regulations, policies and procedures established by Agency. Must have annual negative tuberculin skin test prior to clinical experience. Must have annual influenza vaccine. Contact: Zach Ward- [email protected]

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Palm Beach County Health Department, Florida West Palm Beach, Florida PALMETTO HEALTH, RN-BSN, MSN, USA/Faculty: Submit a comprehensive program of instruction to PALMETTO HEALTH DNP facility two weeks prior to beginning of semester. Submit notification Nurse of assignments as in, dates, hours, number of students, assigned BAPTIST, and PALMETTO Practitioner instructors and type of experience. HEALTH RICHLAND, PALMETTO HEALTH Student: Recommended that all students should receive vaccination BAPTIST PARKRIDGE, for influenza prior to beginning of experience. Must have the following completed within 90 days of entering program: PALMETTO HEALTH 1. Criminal background check for places of residence for TUOMEY, PALMETTO prior seven HEALTH-USC MEDICAL (7) years (SLED required in South Carolina) GROUP (to include all 2. National Sex Offender Registry Database Search departments at Palmetto Health Baptist Columbia, 3. Check of the Office of Inspector General List of Excluded Palmetto Health Richland, Individuals and Entities (LEIE) Palmetto Health Parkridge, 4. Check of the General Services Administration (GSA) list of Palmetto Health Tuomey, excluded individuals/entities Physician Practices at Palmetto Health and Palmetto 5. Federal Criminal File Search Health-USC Medical Group 6. National Criminal File Search and Palmetto Health Corporate Departments located in Columbia, SC).

Palmetto Lowcountry Nursing USA/Faculty: Provide to agency, names and information pertaining to relevant education and training for all students enrolled in the clinical Behavioral Health experience. Must perform a query on the OIG website North Charleston, South (http://exclusions.oig.hhs.gov/Default.aspx) Carolina with respect to contracting student to ensure that the student is not on the exclusions database.

Student: Sign a confidentiality agreement which facility will provide. Palmetto Medical Initiative BSN, RN-BSN, Students: Shall be responsible for Agency program costs as outlined MSN, DNP by Agency, from time to time, for particular programs. Charleston, South Carolina Renewal in process-set to expire 11/13/2018 PAM (Post-Acute Medical) Undergraduate and Graduate Specialty Hospital of Nursing Covington Covington, Louisiana Paragon Contracting MSN, DNP MUST HAVE AN AGREEMENT IN PLACE WITH FACILITY WHERE THE PRECEPTOR IS EMPLOYED BY PARAGON CONTRACTING Services, LLC SERVICES, LLC. Gables, Florida

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered LON Process: Letter of Notification and Appreciation will be filled out a little differently. First, in the first blank, the LON will say "... and thank Facility Name/ Paragon Contracting Services for providing..." Next, the line titled "Preceptor Signature" will now read "Preceptor Signature- Paragon Contracting Services." Thus, the preceptor, as a Paragon employee, will sign as the Paragon official. Lastly, the Agency official will sign on the final, line which reads "Appropriate Agency Official." In summary, only one LON and Appreciation will be used for both agencies instead of two.

USA/Faculty: Notify Paragon and responsible preceptor of the planned schedule of each student assignment, student name, level of academic preparation, and length and dates of the clinical experience. Parkview Medical Center Graduate USA/Faculty: Provide agency with a letter addressing the following: Nursing Specific dates and times during which the educational experiences (includes Parkview Medical Programs will be conducted; Group) Full legal names of each student assigned to the educational Pueblo, Colorado experience; Ratio of students participating in the educational experience (if Renewal in process-set to applicable); expire 12/13/2018 Faculty name and contact information responsible for making student assignments; Proposed scope of student involvement in patient care activities, if any; Description of student learning objectives for each education experience; Orientation schedule for students participating in educational experience; Indication of qualifications for preceptors; Copy of any material preceptors are required to sign prior to participating in the educational experience. Agency contact: Melissa Haro - [email protected] 4000.

Student: Must be current in there licensure.

Peacehealth-St. John Nursing Student-Must obtain a national criminal background check. Must Graduate complete a urine test for prohibited substances. If completed at Medical Student’s facility, student shall reimburse facility for the costs of the test before Center/PeaceHealth their clinical rotation may begin. Students must provide Facility with Southwest Medical Center the location where they received the annual influenza immunization and the date thereof, prior to beginning clinicals. Longview, Washington PeaceHealth-St. Joseph MSN and DNP Agreement for employees of facility only. Student-Must obtain a national criminal background check. Must Medical Center complete a urine test for prohibited substances. If completed at Bellingham, Washington facility, student shall reimburse facility for the costs of the test before their clinical rotation may begin. Students must provide Facility with the location where they received the annual influenza immunization and the date thereof, prior to beginning clinicals.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered

Pediatrix Medical Group, Neonatal and USA/Faculty: Notify the Program Coordinator of the planned Pediatric Acute schedule of the student's assignments, including name of student P.C. and their level of training, length and dates of the student's (Riverside Regional assignment. Medical Center) Glen Allen, Virginia Pediatrix Medical Group of Neonatal Nurse NNP Students Only Practitioner Louisiana, LLC (services Students Only USA/Faculty: Notify the Program Coordinator of the planned Women’s and Children’s schedule of the student's assignments, including name of student Hospital) and their level of training, length and dates of the student's assignment. Lafayette, Louisiana

Pediatrix Medical Group of Graduate Notify Agency of the planned schedule of each student’s assignment, Nursing including name of the student, level of clinical training, length and Nevada (covers: Summerlin dates of the assignment. Hospital, Spring Valley Hospital Medical Center and Sunrise Hospital and Medical Center) Reno, Nevada

Pediatrix Medical Group of Neonatal Nurse Notify Agency through the program coordinator at hospital, of the Practitioner planned schedule of each student’s assignment, including name, Springfield (must have Students level of clinical training, length and dates of the student’s assignment. agreement with affiliated hospital) Springfield, Missouri Pediatrix Medical Group of Undergraduate To utilize agreement, USA must have an existing agreement with and Graduate facility where student will physically be for their clinical experience. Tennessee Nursing Sunrise, FL (main office) USA/Faculty: For Undergraduate students only the University will submit to Affiliate three (3) weeks prior to the beginning of each clinical rotation, a schedule indicating the number and names of students who will be participating and the name of the faculty who will be supervising the students during their rotation. In addition, the University will provide annually to Affiliate a listing of the general time periods for which the facility may be utilized.

Pediatrix Medical Services, Undergraduate and Graduate Inc.(Cook Children’s Hospital, Students Baylor All Saints Medical Center, Texas Health Resources-Harris Methodist Fort Worth, The Woman’s Hospital of Texas and other hospitals in the State of Texas) Richardson, Texas Peninsula Regional Medical RN-BSN, MSN, USA/Faculty: Make available to Agency names of students, dates DNP and times of experience and student learning objectives at least 2 Center weeks prior to placement. (Patricia Serkes 410-543-7412- Salisbury, Maryland [email protected]). Give a copy of the Agency’s Infection Prevention Manual to each student participating in clinicals. Student: Must have all adult immunizations as determined by the Maryland Department of Health and Mental Hygiene and the

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Immunization Practices Advisory Committee. Must be vaccinated against the Hepatitis B. Penn Presbyterian Medical Nursing USA/Faculty: Prior to the commencement of the Program and at least Center thirty (30) days prior to Students going to Agency, SCHOOL will Philadelphia, Pennsylvania provide Agency with adequate written information on the numbers and names of Students being assigned to Agency and clinical experiences needed. SCHOOL shall advise Agency at that time if the Student(s) being assigned to the Program at Agency are also employees of Agency or UPHS

Student: Students must complete the Student Responsibility form. Students must carry adequate health insurance. Graduate Students have a Pennsylvania Registered Nurse License and appropriate degree or certification, if applicable, to participate in this Program. Students must pass a pre-entrance physical examination, which shall include but not be limited to proof of routine immunizations or disease immunity, including measles, mumps, rubella, and Varicella, as well as testing for tuberculosis. Evidence of Hepatitis B immunization (or evidence of informed refusal of Hepatitis B immunization), annual influenza vaccination and any other vaccinations/immunizations as Agency may require from time to time. Students shall make arrangements for the performance of lawful criminal background checks and child abuse clearances in accordance with Pennsylvania Child Protective Services Law, 23 Pa. CSA §6301 et seq., Penn State Milton S. USA/Faculty: Provide education programs regarding OSHA compliance standards for students prior to clinicals. Hershey Medical Center Student: Provide proof of an annual physical examination and Hershey, Pennsylvania provide immunization records. Philadelphia FIGHT Undergraduate and Graduate Community Health Centers Philadelphia, Pennsylvania Phoebe Putney Health BSN, RN-BSN, MSN, DNP System Albany, Georgia

Phoenix Children’s Hospital, Nurse Student must complete Attachments B & C prior to beginning Practitioner clinicals. Inc. Students Phoenix, Arizona Physician Groups, LC dba USA/Faculty: Provide facility with student names, health BJC Medical Group of status reports, immunizations prior to cliniclas. Verify each student has completed and passed the requirements noted in Missouri Exhibit 2. St. Louis, Missouri Students: Complete Exhibit 2-Confidentiality Statement. Provide facility with proof of health insurance.

Piedmont Healthcare, Inc. MSN, DNP USA/Faculty: Provide Agency with overall objectives. Student: Must complete Exhibit A-Student Participation Agreement. (facilities covered by Must maintain personal health insurance. Complete Piedmont’s agreement: Fayette Community Student Orientation Presentation and PHC Code of Conduct as Hospital, Inc. required by Agency. d/b/a Piedmont Fayette Hospital Piedmont Heart Institute, Inc. Piedmont Heart Institute Physicians, Inc.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Piedmont Healthcare Foundation, Inc. Piedmont Henry Hospital, Inc. Piedmont Hospital, Inc. Piedmont Medical Care Corporation, Inc. Piedmont Mountainside Hospital, Inc. Piedmont Newnan Hospital, Inc. Piedmont Newton Hospital Piedmont Athens Regional Atlanta, Georgia Piedmont Medical Center Nursing USA/Faculty: Complete Exhibit C-Attestation. Rock Hill, South Carolina Student: Completed Exhibits A and B. Pikes Peak Hospital & Graduate Prior to any students going to facility USA Nursing Surgery Center Programs FACUTLY MUST CONTACT Woodland Park, Colorado ROBIN HALLAM Renewal in process-set to 719-686-5707 expire 8/1/2018 [email protected] Agency requests the packet come from the school including a bio with the photo of the student.

USA/Faculty: Provide evidence of the following for each student: Tetanus (Tdap): Diphtheria, tetanus, within the last 8 years. Hepatitis B: Documentation of Vaccination 3 dose series. Those Program Participants lacking documentation of injections will be required to offer record of laboratory serology (titers) results. MMR: Documentation of 2 doses MMR vaccine or record of laboratory serology (titers) results. Varicella: Program Participants with no history of exposure to chickenpox will be required to provide documentation of inoculation series (2 shot) or physician documentation of disease or record of positive serology (titer) results. Tuberculin skin test (PPD): Required once a year. If a Program Participant does not have a documented negative skin test result within the preceding 12 months, a two-step baseline must be used. Program Participants with a positive PPD must have a chest x-ray and provide documentation to School that demonstrates no active Tuberculosis. Program Participants should have a repeat PPD if exposed to a patient with active TB. Seasonal flu shot: Hospital reserves the right to require seasonal flu shots. Hepatitis A injection: Currently not required, but strongly recommended. Hospital reserves the right to require other potential vaccinations as guided per recommendations as adopted by any Infection Control Department of the Hospital.

Student: Must complete Exhibits A-C. Pikeville Medical Center BSN, RN-BSN, USA/Faculty: Must complete exhibit A (the document has been MSN, DNP appropriately signed by the Director for Clinical Affairs). Supply Pikeville, Kentucky agency’s rotation supervisor with appropriate forms to be used in evaluating student’s performance. Student: Complete and submit Exhibit B-Statement of Understanding. Pinehurst Medical Clinic BSN, RN-BSN, MSN, DNP Pinehurst, North Carolina

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Planned Parenthood of the RN-BSN, MSN, Contact: DNP Christine Jaynes Contreras Heartland [email protected] Des Moines, IA Renewal in process-set to expire 12/31/2018 Planned Parenthood of MSN Houston and Southeast Texas, Inc. (covers the Planned Parenthood of the Gulf Coast) Houston, Texas

Planned Parenthood of Undergraduate Middle and East Tennessee and Graduate Nursing Nashville, Tennessee Planned Parenthood of SW BSN, RN-BSN, USA Faculty must submit Exhibit A (Curriculum) to agency and MSN, DNP at least 2 months in advance (unless otherwise agreed upon) & Central Florida submit a proposed schedule of student assignments and type of Sarasota, Florida clinical education and training required. Planned Parenthood may require a pre-placement interview with student. Students must meet criminal background screening requirements, as set forth on Exhibit B. Students must maintain health insurance covering injuries or illness. Faculty please send any requirements to: Lauren Brenzel - [email protected] or questions : 941- 365-3913 x 1005

PLLCS Faro MD & Faro MD RN, RN-BSN, Houston, Texas MSN, DNP Renewal in process-set to expire 11/1/2018 Poplar Bluff Regional Nursing Student: Complete Addenda 4-6. Medical Center Poplar Bluff, Missouri Pottstown Hospital and Graduate Student: Complete Exhibit B-Statement of Confidentiality and Consent. Two negative TB skin tests within one year. Tower Health Medical Nursing Programs Group Pottstown, Pennsylvania Practice Plus Nursing At least thirty (30) days before the start of a particular class/rotation, Programs the Program must provide to Practice Plus Human Resources Little Rock, Arkansas Administration with the Educational Participant name(s) and required identifying information, Faculty/preceptor name(s), class/rotation dates and sites, certification of background checks and immunization/medical clearances, and a HIPAA Medical Records Access and Confidentiality Agreement signed by each Educational Participant and Faculty/preceptor. Practice-Plus’s Human Resources Administration must approve the Educational Participant participating at a Practice-Plus Clinic in a program covered by an affiliation agreement prior to the Educational Participant being given access to Practice-Plus Clinic facilities, patients or patient records. Prairie St. John’s Nursing USA/Faculty: Prior to the beginning of clinical, provide information Fargo, North Dakota Programs to the Facility concerning the number of Students, possible dates of

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered assignment, the names and pertinent information about the Students, and the objectives for Students’ clinical education experience.

Student: Must have background check and child abuse clearance checks prior to clinical. Must obtain and maintain health insurance during their clinical experience. Premier Health, Miami Advanced Provide names of students and relevant demographic information Practice and dates of experience at least 30 days prior to student’s arrival. Valley Hospital (with Provide a letter of good standing to Agency. preceptors Dr. Richard Contact is Erin Evans, Student Placement Coordinator, Sanders and/or Dr. Babar 937.208.9145, [email protected]. Must submit evidence of satisfactory health status to Agency. Hasan only) Dayton, Ohio Student: Must complete Exhibits A-C. Premise Health Employer Nursing USA/Faculty: Please provide the following. Beginning dates and length of the Clinical Program to be mutually Solutions, Inc. agreed upon at least 30 days prior to the beginning of the Clinical Brentwood, Tennessee Program; Number of students participating in the Clinical Program; Specific days and hours during which the Clinical Program will occur; Specific locations at which the Clinical Program will occur; Specific learning objectives and performance expectations of the students while on-site at Manager; Specific allocation of responsibilities for the School Liaison and Manager Preceptor, as each term is defined herein; and Deadline and format for student progress reports and evaluation forms; Curriculum and the professional academic credentials of its faculty responsible for the students at facility no later than 30 days prior to clinicals. Provide upon request, a copy of the school’s exposure assessment/determination plan. Student: Provide documentation, upon request, of a negative TB test within the last 12 months or other documentation from a medical provider noting no active Tuberculosis. Student must carry comprehensive health and accident insurance that provides continuous adequate coverage during clinical experience. Presbyterian Healthcare Student must sign and complete Exhibit B prior to beginning clinicals. Services (to include Presbyterian Hospital, Presbyterian Rust Medical Center, Lincoln County Medical Center, Kaseman Hospital, Espanola Hospital, Dr. Dan C. Trigg Memorial Hospital, Plains Regional MC, Socorro General Hospital ) Albuquerque, New Mexico Primary Care and Hope Undergraduate and Graduate Clinic Nursing Murfreesboro, Tennessee Programs Privy Oasis, LLC RN-BSN, MSN, DNP Grapevine, Texas Renewal in process-set to expire 11/16/2018

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered ProHealth Care, Inc. (to USA/Faculty: Provide names and dates of students participating at include: Waukesha Memorial least 3 weeks in advance to Lois Surges [email protected] 262- 928-4403. Hospital, Oconomowoc Memorial Students: Must have health insurance which provides coverage for Hospital, ProHealth Care Medical emergency services while enrolled in program. Must complete the Assoc., Medical Centers) criminal and caregiver background check required by Wisconsin Waukesha, Wisconsin Statutes. Completion of training infection control, OSHA, MSDS, Blood borne pathogen. Promise Healthcare d/b/a Frances Nelson Champaign, Illinois

Providence Health East Graduate Student-Encouraged to acquire health and accident insurance. (Providence Health Care, Nursing Programs Providence Sacred Heart Medical Center and Children’s Hospital, Providence Holy Family Hospital, Providence Medical Group) Spokane, Washington Providence Health and Nursing

Services Background check must be dated less than two years prior to (All Facilities in the Oregon practicum. Any adverse results must be shared with the hospital. Region) Background check verification letter required. HIPAA – DVD and brochure reviews required. Portland, Newberg, Hood River, Seaside, Medford USA Faculty- shall provide facility with program curriculum and objectives. Portland, Oregon Students- Contact Beth Cherry in the Talent Acquisition Team. Must be educated regarding universal precautions, blood-borne pathogens, and other appropriate OSHA standards prior to beginning clinicals. Students must complete checklist for compliance at facility (see attached). It is encouraged that student obtain health and accident insurance.

Providence Health and NP and CNS Background check must be dated less than two years Services prior to practicum. Background check must include an excluded provider search on the Office of Inspector (All Facilities in the Oregon General List of Excluded Individuals/Entities Region) (http://oig.hhs.gov/fraud/exclusions/exclusions_list.asp) Portland, Newberg, Hood and the General Services Administration Excluded River, Seaside, Medford Parties List (http://epls.arnet.gov/) for any students Portland, Oregon participating in or observing experiences at System. Evidence that each student is not on the above mentioned excluded provider list is a condition precedent to Student Affiliation Program placement. Student Health: School/Training Program will provide System a signed attestation, that the below requirements have been met. School/Training Program will further make available to System any and all such documents in the original requested by the System prior to clinical placement upon request. Such inspection will take place within twenty-four (24) hour notice. (a) Hepatitis B:

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered (1) Written documentation of initiation (or completion) of Hepatitis B series or declination statement OR, (2) Laboratory evidence of Hepatitis B status (3) Residents may begin the clinical experience once the Hepatitis B series has been initiated. It is expected that the School/Training Program will assure that the series of injections is completed according to accepted infection control guidelines. (b) Measles, Mumps, Rubella: Written documentation of:

(1) Two doses of measles vaccine on or after the first birthday, plus one dose of mumps vaccine and one dose of rubella vaccine OR, (2) Laboratory evidence of immunity (a positive titer for measles, mumps and rubella antibody) (c) Varicella:

(1) Proof of disease OR, (2) Written documentation of Varicella vaccine OR, (3) Laboratory evidence of immunity (a positive Varicella titer)

(d) TB Surveillance:

(1) Written documentation of a 2-step negative tuberculin skin test (Mantoux) or a Quantiferon Gold test within the past year OR, (2) If TB test positive, written documentation of negative chest x-ray and Negative Symptom Review in the past year

(e) Influenza Vaccine: Written documentation of current year’s seasonal influenza vaccine from Health Care Provider or a declination statement.

(f) Tetanus, Diphtheria, Pertussis (Tdap): Written documentation of vaccine from Health Care Provider

USA Faculty- shall provide facility with program curriculum and objectives.

Students-Must be educated regarding universal precautions, blood-borne pathogens, and other appropriate OSHA standards prior to beginning clinicals. Students must complete checklist for compliance at facility (see attached). It is encouraged that student obtain health and accident insurance.

Providence Health & Nursing Up-to-date Immunizations or titers as required by Hospital policy, Programs including without limitation Rubella, Services – Washington Rubeola, and Mumps (MMR); Varicella (Chicken Pox), Hepatitis B, d/b/a Providence Health and Tdap (Tetanus,

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered & Services Alaska Diphtheria and Pertussis). For tuberculosis testing, student will demonstrate either a negative IGRA Region (covers; or Q-Gold blood test or negative two-step tuberculin skin tests current Providence Alaska Medical Center within the last 30 days, or Providence Behavioral Health one negative chest x-ray for Tuberculosis completed within 12 Services months of beginning the clinical Providence Adolescent Residential education program. USA will provide this documentation upon Treatment Program request. USA will have on file, Providence Center for Child records of positive titer or of immun Development Non-employees must: complete an Alaska background check; Providence Extended Care orientation prior to beginning clinicals. Providence Family Medicine Center Faculty: Must provide agency with a list of students before they Providence Home Health begin clinicals. Student Rotations Coordinator: Amanda Patterson Providence Hospice [email protected] (907) 212-6580. Providence Horizon House Providence Imaging Center Providence Transitional Care Center Providence Senior Care Center The Children's Hospital at Providence Providence Matanuska-Susitna Valley Providence Kodiak Island Medical Center Providence Seward Medical and Care Center Providence Valdez Medical Center) Anchorage, Alaska

Providence Health & USA/Faculty: Will assure that students are educated regarding universal precautions, blood-borne pathogens, and other appropriate Services - Washington d/b/a OSHA standards prior to clinicals. Providence Centralia Students: Must have criminal background check pursuant to Hospital Hospital (to include Policy and “Child and Adult Abuse Laws.” Must include a search on the System for Award Management (SAM) on the background check Providence Regional (http://www.sam.gov). Medical Center Everett and Providence Medical Group- NW Washington Service Area, Providence Medical Group Monroe) Centralia, Washington

Providence Hospital USA/Faculty: Provide the following to the agency: Documentation of Hepatitis B vaccination. Mobile, Alabama Documentation of two step mantoux PPD skin test within last year. Documentation of history of chickenpox and vaccination history of measles and rubella. Documentation of most recent Tetanus Toxoid injection. Documentation of annual Blood borne Pathogen training from University or in the alternative to require students to attend agency’s training session. Students must complete departmental orientation to specific Blood borne Pathogen issues. Provo Canyon Behavioral Nursing USA/Faculty: Provide names and information pertaining to education Programs and training before beginning of clinical experience. Hospital Orem, Utah Student: Must sign a patient confidentiality agreement, which facility will provide. Must obtain criminal background and child abuse clearance checks prior to clinical experience. Provide proof of liability insurance 10 (ten) days prior to start of clinical experience.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Punta Gorda HMA, LLC Nursing USA/Faculty: Please see addenda 1-3 and the student verification checklist. d/b/a Bayfront Health Punta Student: Must completed addenda 4-5 and the student verification Gorda checklist. Must obtain and maintain health insurance coverage. Punta Gorda, Florida

Agency Name Programs Agency Requirements Covered

Agency Name Programs Agency Requirements Covered Rady Children’s Hospital NP USA/Faculty: Inform Facility in writing of level of training each student has received prior to clinicals. Upon request, provide San Diego, California Facility with a copy of each student's academic/educational record. Provide Facility with current information about its curriculum and clinical educational goals and objectives and promptly forward to Facility any change to its curriculum or clinical educational goals prior to the date of such change. Provide student's name and other relevant information to Facility at least 30 days prior to clinicals. Any change to student assignment, must be made at least 2 weeks in advance of the start of assignment, if change or cancellation is last - minute USA Coordinator shall call Facility Clinical Coordinator immediately. USA must notify Facility in writing of names of students and faculty coming to Facility no later than 2 weeks prior to beginning of student assignment. Facility contact: Mara McSparran-Project [email protected].

Student: Background check must be completed no later than 30 days prior to clinical and it to be complete annually while student is at Facility. Must include the disclosure of all counties of residence or work. If student leaves the School's program for 30 days or longer, other than regular scheduled summer break, background check must be completed before student's return to facility.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered

Ralph H. Johnson VA MSN USA/Faculty: Contact Clinical Affairs regarding Influenza Policy. Prior to sending students please provide a TQCVL at least 30 Medical Center days prior to their arrival. Charleston, South Carolina

Rapides Regional Medical RN-BSN, MSN, USA/Faculty: Complete Exhibit C and submit to Agency (Shelley DNP [email protected]) Center Student: Must complete Exhibit A & B. Alexandria, Louisiana Renewal in process-set to expire 7/31/2018 Reading Hospital and MSN and DNP Students: Complete Exhibit B. Must have current complete physical examination and documentation of up-to-date Tower Health Medical immunization status, including the following: Group Proof of immunity against measles, mumps, and rubella (defined Reading, Pennsylvania as a series of two MMR vaccines with complete dates OR positive titers to all three diseases); Tetanus, diphtheria, and acellular pertussis (whooping cough), one lifetime dose of Tdap vaccine. Td or DTAP vaccines are not acceptable; Two negative tuberculin skin tests (TST) one within the past year (a negative serologic test may substitute for the yearly TST); if TST positive, a negative chest X-ray report within the previous three (3) months is required; Proof of immunity against varicella (defined as a series of two Varicella vaccines with complete dates OR a positive antibody test documenting immunity to Varicella; Proof of immunity against Hepatitis B, (defined as a series of three Hepatitis B vaccines and positive anti-HBs antibody testing results post vaccine administration OR a signed declination; and Proof of influenza immunization with current seasonal influenza vaccine or documentation of exemption from influenza vaccine for either of the following reasons, subject to the requirements set forth below: Medical exemption, which includes a history of previous severe allergic reaction to the influenza vaccine or history of Guillain- Barre syndrome within six (6) weeks of receiving a previous influenza vaccine; or Religious exemption, where a Student follows religious beliefs that would prevent the Student from receiving the influenza vaccine because of doctrine or accepted religious/spiritual practices.

Red Stick Emergency Nurse Practitioner Agreement only to be utilized if preceptor is employed by Group, LLC & Baton Red Stick Emergency Group. Rouge General Medical Center Baton Rouge, Louisiana Regional Health MSN Student: Must complete Attachment 1. Rapid City, South Dakota Regional Health Care Undergraduate Agreement begins September 1, 2018 and Graduate Affiliates, Inc. (Health First Nursing Programs Community) Providence, Kentucky Regional Medical Center of Students must sign Exhibits A and B prior to beginning clinicals. Faculty must complete Exhibit C once USA Clinical Affairs has Acadiana verified.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Lafayette, Louisiana Hold Regional One Health MSN, DNP The agency is requesting that, prior to clinicals, student needs to be found free from communicable disease based upon a current (Covers entire hospital health screening. At a minimum, each student will have rubella campus including titer and annual tuberculin testing preformed, with the results outpatient centers, except forwarded to the clinical coordinator of the Hospital. A measles vaccine shall be given and hepatitis B vaccine shall be offered, for Regional One Health unless documented immunity can be established to the Extended Care Hospital ) satisfaction of Hospital. In the event a student elects not to have the hepatitis B vaccine initiated after the risks/benefits have been Memphis, Tennessee fully explained, USA shall obtain from student an appropriate statement documenting such refusal.

Student must have proof of influenza vaccination (this may be included with the attestation form) or to wear a mask during flu season.

Written student evaluation of each clinical rotation and copy of the curriculum, clinical objectives, and student's skill and competency skills. FACULTY: Please send required exhibits (available from the contract office to Lemock, Veronica - [email protected] They can accept these forms electronically. Regional One Health Nursing Obtain written approval from Hospital’s clinical coordinator prior to each experience. Extended Care Hospital Memphis, Tennessee Each student will have rubella titer and annual tuberculin testing performed, with the results forwarded to the clinical coordinator of Hospital. A measles vaccine shall be given and hepatitis B vaccine shall be offered, unless documented immunity can be established to the satisfaction of Hospital. Provide Hospital the following documents: confirmation of the health status of students, written student and faculty (if applicable) evaluations of each clinical rotation; and a copy of the curriculum, clinical objectives and students’ skill and competency levels.

Reynolds Army MSN, DNP USA/Faculty: At least 30 days prior to the beginning of clinicals provide the names of the students, states, hours and clinical Community Hospital activities for which training is being requested. Fort Sill, Oklahoma RHA Health Services, Inc. Nursing Contact-Maureen Motley-Zitin [email protected] Asheville, North Carolina USA please provide the following at least 2 weeks prior to the beginning date of clinicals. Beginning dates and length of the Practicum experience (to be mutually agreed upon at least twenty-one (21) days before students may begin the Practicum experience); Number of students eligible to participate in the Practicum experience; Specific days, hours and locations for the Practicum experience; Specific learning objectives and performance expectations for students; Specific allocation of responsibilities for the faculty liaison, clinical education supervisor and Clinical Site preceptors, if any, identified elsewhere in this Agreement; and Deadlines and format for student progress reports and evaluation forms when appropriate.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered River Oaks Hospital Nursing USA/Faculty: See Addendum 1 & 2 -Patient Care Duties. Student: Complete Addenda 4, 5, and 7. Jackson, Mississippi Renewal in process-set to expire 12/31/2018 River Park Hospital Nursing Provide to Agency, number of students, dates of assignment, name and pertinent information of student. Huntington, West Virginia Riverside Healthcare Graduate Nursing USA/Faculty: Provide to Agency not less than one (1) month prior Students to the commencement of each rotation: (i) the name, address and Association signature of each Student and a proposed schedule of Newport News, Virginia assignment to the Agency; (ii) the expected level of experience to which School proposes each Student will be assigned; (iii) the expected learning objectives of each Student; (iv) a summary of each Student’s education and clinical experience and field work; and (v) the names and phone numbers of School faculty assigned to each clinical area.

Students: Must obtain and maintain their own Professional Liability Insurance in the amounts of $2million per occurrence and annual aggregate limits of $3million. Maintain health insurance during clinical experience. Riverview Health Graduate Please see Exhibit A. Notify Agency at least sixty days prior to the beginning of each Noblesville, Indiana Nursing Programs clinical experience. Contact: Cheryl Nogoda [email protected] Robertsdale Rehabilitation Undergraduate and Healthcare Center and Graduate Nursing (Ball Healthcare Center) Robertsdale, Alabama Rockford Memorial Nursing USA/Faculty: Must provide necessary evidence of student’s current physical examination and immunizations. Hospital, Rockford Health Physicians, and the VNA of the Rockford Area Rockford, Illinois Renewal in process-set to expire 8/3/2018 Rush Health System (to BSN, RN-BSN, include all of its subsidiaries and MSN, DNP affiliated entities) Meridian, Mississippi

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Sacred Heart Health System (Medical MSN, DNP Students per the facility, make contact Group’s affiliated with Sacred Heart via email, instead of coming to the are covered by the agreement) clinic. Students who just show up will Pensacola, Florida be turned away.

Please see ALL onboarding documents for undergraduate and graduate clinical experience.

Please send onboarding forms to: [email protected] Agency Contacts: Wendy E. Miller, DNP, RN, CNE Clinical Education Coordinator Office: 850-416-7258

Patricia Born, BSN, RN Patient Educator/Student Onboarding Office: 850-416-7258

Students must review Exhibit A and complete Application for Residents and Students prior to starting clinicals. See course coordinators. Students must follow flu vaccine policy, available through the contract office. Saddleback Memorial Medical Center USA/Faculty: USA must certify the student has completed the required training in HIPPA Laguna Hills, California compliance and blood and body fluid standard Renewal in process-set to expire precautions consistent with the Center for Disease Control guidelines. Must provide Facility with course 7/31/2018 objectives for the program prior to the beginning of clinicals. All student information requested from Facility must be submitted within 2 weeks of student beginning clinicals.

Students: Must maintain adequate healthcare coverage. Must have received training in HIPPA compliance and blood and body fluid standard precautions consistent with the Center for Disease Control guidelines. Also to complete any Facility orientation requirements.

Saint Alphonsus Health System (to Nursing Programs MUST BE RESIDENTS OF IDAHO include: Nampa, Idaho and Boise, OR OREGON Idaho) USA/Faculty: Please see Exhibits A & B for Boise, Idaho Background Check and Immunization Requirements. Provide written notice to agency not less than 45 days prior to start date (Internship Request). Request must contain, student name, desired profession of Internship, the Saint Alphonsus facility, Preceptor name, start date, desired length of Internship, Letter of good standing. In the event student will perform any research, USA shall disclose any Research it is then aware of in the Internship Request. Provide annual report that summarizes Internship to indicate the extent to which the objectives were fulfilled. Contact: Kim Philipps 208-367-2159 or [email protected]

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Student-May be required to participate in interview either by phone or in person, Complete and Sign Exhibits C -Confidentiality Agreement and Exhibit D- Student Agreement. Saint Francis Health System, Inc. GRADUATE All background and drug screen results should be provided to the agency. Tulsa, Oklahoma Saint Francis Hospital-Bartlett Student: Must complete Exhibit A-Statement of (effective 8/1/2015) Responsibility and Exhibit B-Confidentiality Statement. Bartlett, Tennessee Saint Francis Medical Center Student must complete and sign Exhibit A. Faculty please see Exhibit B. Adult Gerontological Acute Grand Island, Nebraska Care NP program. Saint Joseph Mercy Health System (to Nursing Programs Agency Contact: Judy Phillips include: St. Joseph Mercy Ann Arbor, St. Education Department Joseph Mercy Oakland, St. Joseph Mercy [email protected] Livingston, St. Mary Mercy Livonia, and St. Joseph Mercy Chelsea) USA/Faculty: Complete the Immunization Checklist. Provide Agency with advance notice of the Ann Arbor, Michigan Program’s requirements for each clinical experience. Students: Complete Exhibits A-C. Saint Mary’s Regional Medical Center Graduate Nursing Students: Complete Exhibits A&B. Students Russellville, Arkansas Saint Peter’s University Hospital APRN Nursing Any on-site Faculty (site visits) will need to be Education licensed in the State of New Jersey. New Brunswick, New Jersey Ensure Faculty and Students meet the AGENCY requirements for health screening clearance, equivalent to AGENCY requirements for Saint Peter’s University Hospital employed personnel, including:

(1) Two-step Tuberculosis Test (“TST”), with Chest X-ray if TST positive; (2) Rubella, Rubeola, Mumps, Varicella titers; (3) Hepatitis B Antibody and Antigen; (4) Hepatitis C Antibody; (5) Five Panel Drug Screen; (6) Proof of physical examination, noting free of any contagious disease; (7) Flu vaccination annually or signed declination.

USA will provide AGENCY with a letter within two weeks prior to clinical experience confirming that the health requirements stipulated by this Agreement have been verified by USA.

Saint Luke’s Health System (covered Nursing LON IS NOT REQUIRED-Faculty follow steps from by agreement; Saint Luke’s Hospital of the “In Lieu of an LON” document. Kansas City, Saint Luke’s South Facility contact: Hospital, Saint Luke’s East Hospital, Jasmine Heinson Program Coordinator Educational Services Saint Luke’s Northland Hospital Corp, [email protected] Crittenton, Wright Memorial Hospital, Number of students, beginning and ending dates will be agreed upon by Facility. Anderson County Hospital, Saint Student: Must have documentation from the Luke’s Cushing Hospital, Hedrick Missouri Department of Social Services stating they

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Medical Center, Saint Luke’s Medical are not on the Employee Disqualifications List. Must have color blindness screen. Group, Saint Luke’s Cardiovascular Immunizations/Testing/Health Documentation. Prior Consultants, Saint Luke’s Neurological to the commencement of any Program activities, Consultants, SLN Medical Specialists, School shall provide documentation of the following immunizations/medical tests (the “Immunizations”) Saint Luke’s Physician Specialists, with respect to each Student participating in the Midwest Ear Institute, Inc., Program: TB screen within past 30 days upon admission (if TB Kansas City, Missouri screen is over 30 days old, a new TB screen is required, if a TB screen has never been done, either a 2-Step TB screen or a TB blood assay test must be completed); Current influenza vaccine; Measles/mumps vaccination — proof of vaccination or, for staff or agents born on or after 1/1/57, adequate documentation of diagnosed disease, laboratory evidence of immunity; Varicella (Chickenpox) — proof of vaccination, physician diagnosed disease or, for those with a negative or uncertain history of varicella, positive serologic screening; Hepatitis B (immunization documentation or vaccination, as recommended by the CDC; can waive, if documented); Rubella — for students born on or after 1/1/57, adequate documentation of diagnosed disease, laboratory evidence of immunity; all women, regardless of birth date, should have proof of rubella immunity or prior vaccination; Tetanus-Diphtheria-Acellular Pertussis — after the initial series, the booster given at 10 years should be Tetanus, diphtheria and acellular pertussis (TDaP). Irrespective of when the last Td vaccine was received, a student must have received a dose of TDaP; Proof of health insurance (or waiver); and Successful completion of orientation exam.

Saint Mary’s of Michigan Standish Hospital Saginaw, Michigan Saline Memorial Hospital Nursing Programs Students: Must complete and return the Agency’s Orientation packet prior to assignment at agency. Benton, Arkansas Must complete Exhibits A&B. Tuberculin skin test within the past twelve (12) months or documentation as a previous positive reactor; and Proof of Rubeola immunity by positive antibody titers or two (2) doses of MMR; and Varicella immunity, by positive history of chickenpox or proof of Varicella immunization; and Proof of Hepatitis B immunization or declination of vaccine, if patient contact is anticipated. Samaritan Health Services, Inc. USA/Faculty: Complete Letter of Good Standing from Agency. Corvallis, Oregon Provide agency with copies of curriculum, education goals, and requirements and qualifications of Students. Provide agency with clinical rotation plan and clinical education objectives for the Learning Practicum for agency’s review.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Students: Provide own health insurance. San Angelo Community Medical Nurse Practitioner USA/Faculty: See Exhibit of Student Duties Students can/cannot provide. Center and Community Medical Student: Complete Addenda 4-6. Associates San Angelo, Texas Negative TB skin test within the past year or, in the event of a positive TB skin test, a chest x-ray within the past three (3) years; OR provide evidence of no TB disease per negative result of interferon-gamma release assay blood test (T-Spot or Quantiferon Gold) within twelve (12) months of student activity at facility; (b) a completed series of Hepatitis-B vaccine, having begun the series, or informed refusal of the vaccine; and (c) any other appropriate immunizations requested by Facility.

Office of Inspector General (“OIG”) List of Excluded Individuals/Entities School shall not refer Students who have been suspended or disbarred from any applicable federal payer program. Appropriate screening tools include the Excluded Party Search System, or approved software programs, and certain internet sites.

San Antonio Metropolitan Health Undergraduate See Attachments 1&2. and Graduate Provide Agency, as needed, with copies of course District Programs outlines, objectives, curriculum, philosophy and San Antonio, Texas method of evaluations. Students must attend mandatory orientation.

San Antonio Regional Health Undergraduate Prior to clinical placement, each student will be Upland, California and Graduate tested for tuberculosis with the PPD skin test Nursing within one year or if the student has a history Students of positive skin tests they will have a chest x- ray within the last three years in accordance with Hospital Policy. Chest x-rays will be accompanied by a TB questionnaire. Prior to clinical placement, each student take or decline the Hepatitis B series. Documentation will remain on file.

Prior to clinical placement; each student is required to have the influenza vaccine. The only exception to receiving vaccination is documentation of a serious event including anaphylaxis, or Guillian Barre following the flu vaccination. If this is documented, the student will be required to wear a surgical mask in any area where there are patients from November 1stthrough March 31st.

Prior to clinical placement, each student will provide to University documentation of required immunization(s) as follows: Measles, Mumps, Rubella (MMR), Tetanus/Diphtheria booster, Chickenpox.

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Agency Name Programs Agency Requirements Covered Prior to clinical placement, a background check will be conducted at the expense of the student.

Sanford Health-Bismarck Agency contact: Alana Erstad-701-323-6375- [email protected]. Bismarck, North Dakota Preventive health requirement form has to be *Only for the Bismarck Sites* completed on student. Student must complete Net Learning System. Mandatory influenza vaccinations for students-October1st through March 31st. Students must have background check completed at least one year prior to clinicals. Sanford Health ALL: please see the updated forms and information regarding the Ebola virus: Please be advised that, Sioux Falls, South Dakota following the CDC’s recent alert regarding confirmed cases of Ebola in the country of Mali, Sanford is now screening for travel to Mali, as well as Guinea, Liberia and Sierra Leone. Accordingly, attached, please find revised versions of the Interim HR Ebola Related Protocols and Pre-Employment Travel Questions Guide for Recruiters, which have been updated to include Mali as one of the Impacted Regions. Also attached for your reference, please find the CDC’s Interim U.S. Guidance for Monitoring and Movement of Persons with Potential Ebola Virus Exposure (October 27, 2014).

Students must review and complete the Sanford Health Orient Action Packet, please note the directions for sending the forms. They can be faxed to 605-312-9837 or scanned/emailed to: [email protected] USA/Faculty: Program Faculty must be appropriately licensed in the applicable state where the program activities will be performed. Submit upon request the program philosophy, objectives, and type of learning experience desired. Dates, times, number, and academic level of students assigned to clinicals. Name, license number, and credentials of faculty member providing practicum instruction. Student: Must have current influenza vaccination, physical exam showing good health, TB skin test within the last 12 months, Hepatitis B vaccine (3 doses are recommended, but not required prior to clinical). Provide Facility's Office of Academic Affairs with the results of the national background check and criminal screening, must be completed within one year of student’s clinical at Sanford Health. Sanford North See Exhibit A for covered locations.

Fargo, North Dakota USA Faculty must provide the following to Sanford upon request: Program philosophy, objectives and type of learning experience desired. Dates, time, number and academic level of students to be assigned to each unit within Sanford.

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Agency Name Programs Agency Requirements Covered Name, license number, and credentials of faculty member providing practicum instruction, if applicable. Prior notice of any proposed changes to any assigned student's schedule.

Santa Clara Valley Medical Center and USA/Faculty: Agency contact-Michael Perry - [email protected]. Santa Clara Valley Health and Hospital Required annual health screening clearing student System to participate in the clinical training program with no San Jose, California restrictions. Written documentation of immune status for the following: Rubella and Mumps Rubeola Varicella Hepatitis B Written documentation of TB screening by TB Skin Test or Interferon Gamma Release Assay. Annual fit test results with the health care particulate respirator N95 in use at facility. Written documentation of flu vaccine or completed declination form. Written documentation of T-Dap or completed declination form. Please see the facility's Infection Prevention Policy under the Employee Health Infection Prevention Program (available through facility).

Students: Must complete Exhibits C (Security and Confidentiality Agreement) & D (Confidentiality of Patient and Employee Information), submit to the facility. Required annual health screening clearing student to participate in the clinical training program with no restrictions. Obtain a photographic identification badge from the County and wear badge at all times while participating in the clinical training program. Santa Rosa Medical Center USA/Faculty: Must submit all coordinating information for student and clinical to Cindy Sallas Milton, Florida Director, Medical Staff Services Santa Rosa Medical Renewal in process-set to expire Center (850) 626-5106 [email protected]. Must complete attestation form (Exhibit C-attached) 10/10/2018 and submit to agency. Student: Must sign a Statement of Responsibility and a Statement of Confidentiality (Exhibit A- B- attached). Should you have any questions, please let me know. Must secure health insurance coverage through approved provider by Hospital. Santa Rosa Public Health Department Milton, Florida Saraland Senior Center Undergraduate Saraland, Alabama and Graduate Students Sarasota Memorial Health System Sarasota, Florida Effective 1/19/2018, All Nursing and Allied Health Students assigned to Clinical Rotations on the Main Campus, between 6:00 AM and 8:00 PM, M-F, are required to park at the Briggs Ave. Garage and utilize the Shuttle Service. Any student vehicle found in violation of this directive will be towed at the owner’s expense.

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Agency Name Programs Agency Requirements Covered USA must notify the agency of the names and number of students and period of clinical four months prior to the beginning of clinical. USA must complete and sign Exhibit A-Attestation.

All students must have a physical exam prior to beginning clinicals. All students who are unable to take the influenza vaccination will be required to wear a surgical mask. Student must have a current criminal background search (within one year), which may include a Level 2 Screening, this will be the responsibility of the student, including any fees associated, (Exhibit B) when required. Students in the Advanced Registered Nurse Practitioner (ARNP) program must provide information to the Medical Staff office. Seattle Children’s Hospital Nursing SEATTLE CHILDREN EMPLOYEES ONLY Seattle, Washington USA Faculty: Complete Letter of Agreement and provide to Facility. Contact: Jackie Smith - [email protected]. See Immunization and Health Requirements document. Students: Should obtain health and accident insurance.

Select Specialty Hospital -Gulf Coast, Inc. Gulfport, Mississippi Select Specialty Hospital USA/Faculty: Please see student requirements.

Tallahassee, Florida Student: Must acknowledge in writing to Facility that they have review and understand the Hospital's Policies and Procedures and have no questions regarding the standards set forth in the Policies and Procedures (Provided by Facility). Students must undergo training on the HIPAA, prior to clinicals. Must have had instruction in accordance with the federal guidelines "Occupational Exposure to Bloodborne Pathogens" and instruction in exposure to tuberculosis, protective practices to avoid contamination, and procedures in case of exposure or potential exposure in accordance with the federal guidelines "Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health Care Facilities". Must have PPD within the last year showing on record freedom of tuberculosis. Student must show they have either received Hep B vaccine or signed a declination form.

Sentara Healthcare System (includes: MSN and DNP USA/Faculty: Must receive a copy of Sentara Leigh Hospital, Sentara Norfolk student’s professional liability insurance General Hospital, Sentara Careplex for the file.

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Agency Name Programs Agency Requirements Covered Hospital, Sentara Virginia Beach Students: must purchase professional General Hospital, Sentara Williamsburg liability insurance (outside of USA) in a Regional Medical Center, Sentara Obici minimum amount equal to not less than the Hospital, Sentara Princess Anne limitation on recovery per occurrence specified in Section 8.01-581.15 of the Code of Virginia Hospital, Sentara Potomac Hospital, ( current code is available from the USA Rockingham Memorial Hospital, Martha Clinical Affairs Department) in order to intern Jefferson H.ospital, Halifax Regional at this site, since Virginia law requires higher Hospital, Sentara Medical Group, limits that the University offers. Sentara Nursing Center - Norfolk, Sentara Nursing Center - Hampton, Sentara Nursing Center - Portsmouth, Sentara Nursing Center - Virginia Beach, Sentara Nursing Center - Chesapeake, Sentara Home Health Chesapeake, Virginia Seton Medical Management (covers the Undergraduate Cancer Center-Radiation/Oncology, Providence and Graduate Surgical Services, Providence Surgical Nursing Specialties) Students Mobile, Alabama Severna Park Center Nurse Practitioner Students must maintain health insurance coverage while in clinicals at Facility. Annapolis, Maryland Shands Jacksonville Medical Center ALL REQUESTS FOR CLINICAL ROTATIONS MUST COME FROM FACULTY. Students must Jacksonville, Florida have photo student ID and complete Shands’ orientation prior to beginning clinicals. Exhibit A requirements from student and faculty. ALL REQUESTS FOR CLINICAL ROTATIONS MUST COME FROM FACULTY.. Faculty should contact Dani Brown - [email protected] and she will provide Shands’ orientation packet. Shands Lake Shore Regional Medical Nurse Student: Complete Addenda 4 & 5 - submit to Practitioner agency. Must have OSHA Blood borne pathogens Center standards and tuberculosis transmission prevention Lake City, Florida training prior to clinicals. Must have health insurance during their clinicals at Facility.

Shands Teaching Hospital and Clinics Nursing Students must complete Exhibit A before starting clinicals. (NON EMPLOYEES ONLY). d/b/a Shands at the University of Florida (ONLY COVERS THE Students must complete Exhibit A before starting clinicals. HOSPITAL) ALL REQUESTS FOR CLINICAL ROTATIONS Gainesville, Florida MUST COME FROM FACULTY. Agency contact: Jean [email protected] Sharp HealthCare Family Psych and Faculty: must contact Claudia Bock at 858-499- Nursing 5366 or by email at [email protected] to fill San Diego, California Informatics out a roster of students being placed at Sharp. (covers: Sharp Metropolitan Medical Campus Faculty who will be on site with students need to Sharp Memorial Hospital Preceptors must contact Barbara DeFulvio at 585-499-5244 or be SHARP [email protected]. Faculty web site is Sharp Outpatient Pavilion Employees (does http://www.sharp.com/ Sharp Home Care not include Sharp Mesa Vista Hospital Medical Staff) Students: need to access the following web site www.sharp.com/b2b/students.cfm. Sharp McDonald Center

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Agency Name Programs Agency Requirements Covered Sharp Mary Birch Hospital for Women & To make sure that the students background checks and drug screening requirements are complete, Newborns please see Attachment A. Sharp Grossmont Hospital Agency may require the student to purchase full “tail Sharp Hospice “insurance to cover student’s activities during term of Sharp Chula Vista Medical Center agreement. Sharp Coronado Hospital and HealthCare Center Sharp Rees-Stealy – all locations Sharp HealthCare – all corporate locations)

NURSING INFORMATICS and FAMILY PSYCHIATRIC NP PROGRAM ONLY

Sheridan Children’s Healthcare of Neonatal NP Only NEONATAL NP ONLY Texas, P.A. Plano, Texas Sheridan Children’s Healthcare Services, Inc. Plantation, Florida Sheridan Children’s Healthcare Neonatal 2018 Updated Badge Info: Services and South Broward Hospital Nurse What you and the students need to do District d/b/a Memorial Healthcare Practitioner for every profiles/rotations created as System (Memorial includes: Memorial Program of 1/1/18 Regional, Memorial Regional Hospital South, Students Joe DiMaggio Children’s Hospital, Memorial ONLY Hospital Pembroke, Memorial Hospital West, Memorial Hospital Miramar) 1. The student badge form is now Hollywood, Florida an electronic form in Complio. The student fills it out and signs it right in Complio.

2. Students who have never been issued an MHS badge will check the box “initial student ID badge” and pay $5 for the badge in Complio. MHS will no longer collect money or send the student to the cashier.

3. Students who have an MHS badge in their possession will check the box “renewal of student ID badge” and will not have to pay for the badge in Complio. They will exchange their hospital-specific badge for a new MHS system badge at the hospital where they are going to.

4. Students who have lost their MHS badge will check the box “lost student

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered ID badge” and pay $5 for the badge in Complio.

5. The school Complio administrator shares the completed profiles/rotations with MHS.

6. The profiles/rotations is accepted by the receiving MHS hospital.

7. Complio sends an email to the student with the completed badge form. The student can also retrieve a copy of the email in their Complio communication/message center.

8. The new badge form will say “paid” on the left hand side AND “approved” on the right hand side like the sample attached.

9. The student prints the “paid” and “approved” badge form and reads the badging location days/hours on page 3 that pertain to the hospital that they are going to.

10. The students goes to the correct facility during the days/hours listed 2-3 days before the start of the rotation to get the MHS system student badge.

11. Students are not allowed to start a rotation without a properly issued student badge.

Other information:

· Facilities will not issue badges on the same day that the rotation is to start unless prior arrangements are made and approved by the Director of Education and the badging personnel.

The badge will be active until the expiration date which is clearly visible on the badge. If the student loses the

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered badge or extends/renews the rotation, the student must go back to the badging section in Complio, make the needed changes and print a new badge form to get a new badge.

A student who breaches security policies by entering MHS with an expired badge or a visitor pass will be escorted to security. The badge may be confiscated, the school will be contacted and their rotation at MHS may be canceled. All MHS employees have been instructed to look for expired badges.

There is a transition period of 3 months. MHS will accept old badge forms for profiles/rotations created before 1/1/18 until March 30th. All students who come as of 4/1/18 with an old badge form will be turned away.

The school or the student will continue to share the student’s profile to each location with the correct start and end dates. An MHS hospital will not accept the profiles of students going to another MHS hospital. Please continue to create rotations and share them as you have done in the past.

Every school can use the button "View Rotation Requirement Details" by going to their Services ----> Rotations ----> Manage Rotation---> (locate your rotation in question) ----> Details link ----"View Rotation Requirement Details button to download the requirements for that particular rotation. This will state the badge form process for that particular rotation.

Door access is hospital specific. If a student has a need for access to a specific area, the preceptor for that student must ask security for that access via email and the student may need to report to the badging office to have that access added.

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Agency Name Programs Agency Requirements Covered

The badge will be accompanied by a badge buddy. The badging office will give the student the correct badge buddy: STUDENT, AA STUDENT LEVEL 1, AA STUDENT LEVEL 2, SRNA LEVEL 1 AND SRNA LEVEL 2. The badging office will issue a level 2 badge and badge buddy for anesthesia assistant students and SRNAs after getting confirmation of the change from level 1 to level 2 from Wanda Diaz.

The student will get to keep the badge as a souvenir at the end of their time with MHS.

PLEASE NOTE: All students that are approved to do a rotation at any of the MHS facility must first pay the $10.00 cashier fee then go to security for a student badge prior to entering the facility. We have had some students not follow proper procedure and disregarded MHS safety and security measures by failing to obtain a student badge before starting their rotation. As of 2/21/17, failure of any student to follow this process will result in the immediate termination of their clinical rotation. In addition, continued disregard of the process by students of a particular program may result in the termination of the affiliation agreement for that program.

Faculty must submit Letter of Understanding (see agency attachments) to Memorial for each student with a copy to USA Clinical Affairs Office Student may be required to purchase general liability insurance if applicable. Please see letter outlining additional onboarding process and fees.

Please read the requirements below:

Here are the steps that are required for all students prior to starting a rotation at MHS.

· Students need to enter their profile information into the Complio Database share it with their school and then you, at

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Agency Name Programs Agency Requirements Covered the school, will share it with MHS. Please note all checkmarks need to be in green in order for the file to be considered complete.

· Once I am able to view the student’s profile, I can then accept the profile and set the student up for a badge ant IT access (if IT access is needed). You will be able to see on your end when I have accepted the profile.

· Please note it is my responsibility to notify security that the students are compliant. Please refrain from telling students to go to security. Any student who shows up at the security office without being approved by me will be sent home. The officers at each of the badging offices will only accept an email about approved students from me.

· All student need to make sure to print the badge form and at that time student will need to go to the discharge lounge (cashier office) near gift shop at Memorial Regional, pay a $10.00 fee and then go to Security to get their student ID. (Not every student will be at the Memorial Regional Hospital so please contact your preceptor to find out which location your student needs to report to.). The hospital- specific badge form in Complio will tell the student exactly what they need to do and where they have to go. Please have the student follow instructions in the paperwork provided regarding the location for payment. Students have 30 days from the end date to return their badge to the same location they originally received it in order to get their money back.

Please note that no student will be able to start a rotation if the proper steps are not completed. In order to avoid any delays please be sure to share the student’s profile with me at least 2 weeks prior start date.

Sheridan VAMC Faculty must send a Program Letter to Ms. Beverly Bernard at [email protected], letter must Sheridan, Wyoming identify faculty, including VA employees, who will teach, supervise, and evaluate trainee performance; outline educational objectives; specify periods and clinical area of assignments. Sibley Heart Center and Affiliates Nursing Please see Exhibits A-C (Participant Agreement and Requirements). Atlanta, Georgia Renewal in process-set to expire 12/31/2018

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Silverton Health USA must provide written notice to Facility of student placement request at least 30 days prior to their Silverton, Oregon arrival, to include student name and class Renewal in process-set to expire objectives. Student must have educational training in Blood borne Pathogens, BLS, Sliverton Health 10/3/2018 online competency lessons. Flu Vaccine (October- March). Facility contact: Jocelyn Lewis at [email protected] or 503-873-5292.

Faculty: Students and their perspective sites must be approved by the Oregon Board of Nursing through USA’s Contract Office. USA Faculty must have a Oregon APRN license.

SIMEDHealth Undergraduate Clinical Affairs-note insurance amounts for verification of liability. See agreement before issuing. Gainesville, Florida and Graduate Nursing Students Singing River Health System (Singing Nursing River Hospital and Ocean Springs Hospital) Pascagoula, Mississippi Sisters of Charity Providence Hospital Faculty should contact Tajuane Dockery 803-865- 4793 [email protected] to Columbia, South Carolina schedule students participating in clinicals.

Students complete Exhibit B. Slidell Memorial Hospital & Medical Nursing USA/Faculty: Must provide the following to agency at least 3 weeks prior to actual assignments: Center Roster of Students (including list of competencies Slidell, Louisiana and evaluation forms. Clinical practice assignments with scheduled rotations. Brief name of course description for the required learning experience. Soin Medical Center (Kettering Health USA Faculty: Must provide all objectives, policies, and evaluation instruments to be utilized to Network affiliate) preceptors. Review Exhibit A (Immunization Beaver Creek, Ohio Requirements).

Students: Must complete and sign Exhibit B. Must provide Hospital with documentation evidencing background check. Must provide proof of health insurance to Hospital.

Sound Physicians Graduate Nursing Programs Tacoma, Washington (Only to be used in conjunction with a completed Onslow Memorial Hospital Agreement) South Arkansas Emergency Advanced Practice Provide preceptor a list of students no fewer than 7 Only days prior to the start of the clinical experience. Physicians, LLP Provide a copy of the USA CON’s preceptor Little Rock, Arkansas guidelines. South Baldwin Regional Medical Student must provide written evidence of negative TB test within the past year or chest x-ray within last Center 3 years, written documentation of a completed

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Agency Name Programs Agency Requirements Covered Foley, Alabama Hepatitis B vaccine or one has begun the series. Students must submit to substance abuse testing Note: If a student is requesting every 12 months (to test for presence of alcohol, placement at one of the Medical Group drugs, or other controlled substances). locations, please email [email protected]. Renewal in process-set to expire 8/31/2018

South Carolina Department of Health Nursing USA/Faculty: Provide to Agency names of and Environmental Control students, objectives and dates for each student in a clinical experience at Agency. Columbia, South Carolina Student: Must obtain Health Insurance during experience. South Carolina Department of Mental Health (Division of Inpatient Services) Columbia, South Carolina Renewal in process-set to expire 12/31/2018 South Carolina Group Services, LLC Nursing To utilize this agreement, USA must have an agreement in place with the facility where clinicals (ApolloMD) will take place. Atlanta, GA (main office) South Central Regional Medical Center BSN, RN-BSN, USA CLINICAL AFFAIRS-SEE IINSURANCE MSN, DNP SECTION 4(j) page 6. (covers all clinics) Laurel, Mississippi

South Central Hospitalists, LLP Advanced Practice Provide preceptor a list of students no fewer than 7 Only days prior to the start of the clinical experience. Bentonville, Arkansas Provide a copy of the USA CON’s preceptor guidelines. South Jersey Hospital, Inc. (aka Bridgeton Mental Health Unit) Bridgeton, New Jersey South Lake Hospital Undergraduate and Graduate Clermont, Florida Nursing Southcoast Hospitals Group, Inc. Students and on-site instructors must complete 10 panel urine drug tests prior to beginning clinicals. New Bedford, Massachusetts Students must complete the student/Instructor Confidentiality Agreement. Southeast Alabama Medical Center Undergraduate USA/Faculty: Please see NP Student Rotation and Graduate Application. Dothan, Alabama Nursing Southeast Regional Primary Care Nursing Programs Students are required to utilize MyClinicalExchange for all clinical rotations. Corporation (to include Dublin Internal Medicine and Vidalia Women’s Center) USA/Faculty: Provide written clinical behavioral Vidalia, Georgia objectives to facility prior to clinicals. Submit a schedule with names of students at least two weeks prior to clinicals. (Priscilla Edge-Payer Enrollment Administrator-912-538-5314- [email protected])

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Student: Submit health records to facility at least two weeks prior to clinicals. Urine Drug Screen may be requested by facility. If student has had a break in enrollment, student will need new background check. Southeastern Emergency Physicians, MSN and DNP USA must have agreement with facility where student will physically be. This agreement covers the LLC (Team Health) (covers Maury preceptor the agency employs. Regional and Baptist Health Paducah facility) Knoxville, Tennessee (Main) Southeastern Regional Medical MSN and DNP USA/Faculty: Provide curriculum of program to agency. Center, Inc. See Exhibit B Specific Requirements. Newman, Georgia Southern Alabama Physicians, LLP Undergraduate and Graduate Traverse City, Michigan Southern Crescent Behavioral Health Graduate Nursing USA/Faculty: Provide the names and information Students pertaining to relevant education and training for all System (Anchor Hospital and Crescent Students enrolled in the clinical education program Pines Campus) within a reasonable time before the beginning date Atlanta, Georgia of the clinical education program. University is responsible for supplying any additional information required by Facility as set forth in this Agreement, prior to the arrival of Students. University will notify Facility in writing of any change or proposed change in a Student’s status. Southern Illinois Hospital Services (to Graduate Nursing USA/ Faculty: Not less than one week prior to and Nurse clinicals, provide a list of Students to appropriate include: Memorial Hospital of Carbondale, Practitioner departments at facility, physical exam within last 12 Herrin Hospital, St. Joseph Memorial months, evidence of TB tes (step 2), chest x-ray for Hospital-Hospital settings) students with a positive TB skin test, MMR Carbondale, Illinois immunization, Hepatitis B vaccine, or provide a signed waiver, screen for varicella immunity, valid current certification in CPR. Provide information and training regarding exposure to bloodborne pathogens consistent with the standards applicable for compliance with the final regulations issued by OSHA. Student: Maintain health insurance during their participation in the program at facility. Attend all required orientation at facility. Must obtain a successful completion of a urine drug test within seven days prior to clinical start date. Student must report to WorkCare (500 Lincoln Drive, Suite D, Herrin, Illinoise) for pre-assignment testing. Failing the drug test will result in withdrawal of clinical assignment for one year. Southern Illinois Medical Services, Nurse Practitioner USA/ Faculty: Not less than one week prior to and MSN clinicals, provide a list of Students to appropriate NFP (covers the medical practice and Programs departments at facility, physical exam within last 12 clinic settings) months, evidence of TB test (step 2), chest x-ray for Carbondale, Illinois students with a positive TB skin test, MMR immunization, Hepatitis B vaccine, or provide a signed waiver, screen for varicella immunity, valid current certification in CPR. Provide information and training regarding exposure to blood borne pathogens consistent with the standards applicable for compliance with the final regulations issued by OSHA.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Student: Maintain health insurance during their participation in the program at facility. Attend all required orientation at facility. Must obtain a successful completion of a urine drug test within seven days prior to clinical start date. Student must report to WorkCare (500 Lincoln Drive, Suite D, Herrin, Illinois) for pre-assignment testing. Failing the drug test will result in withdrawal of clinical assignment for one year. SIU-Southern Illinois University Nursing USA-Provide Agency with the overall objectives of the academic program and provide the appropriate Springfield, Illinois educational objectives and documents for clinical experiences.

All students must have the following immunizations with documentation available upon request: TB skin test. The test or chest x-ray must be negative. Rubella (German Measles) immunization or positive Rubella Screen or titer. Rubeola (Red Measles) immunization or positive Rubeola Screen or titer. Mumps immunization in 1969 or later or physician diagnosed illness. (After 1969, written documentation of immunization of live mumps vaccine at 12 months of age or later.) MMR (Mumps, Measles, Rubella) immunization. (Two doses of MMR separated by more than one month and given on or after the first birthday eliminate the need for 2, 3, and 4 above.) Hepatitis B Vaccination: USA shall submit evidence to Agency that each student has received Hepatitis B vaccinations. Southern Indiana Rehab Hospital All Nursing Exhibits A & B must be completed prior to beginning Programs clinical rotation. In addition, School must verify New Albany, Indiana negative status of Kentucky Board of Nursing Abuse Registry check prior to commencement of the clinical experience. Southern Maine Health Care-Maine Nursing Student: Must read Safety Tips, complete Sign Off form and Confidentiality Statement. Health Biddeford, Maine

Southern New Hampshire Health Nursing USA/Faculty: Must provide written notice of each new student to be covered by the agreement at System (includes Southern New least 30 days in advance. Provide a detailed Hampshire Medical Center and Foundation description of the educational experience anticipated Medical Partners Physician Offices) the student will have while at Agency, including specific objectives and instructional methods, Nashua, New Hampshire detailed course syllabus.

Student: Must have a criminal background check within a 90-day period immediately prior to their initial placement at facility (State of NH Department of Safety Criminal Background Check as well as a national criminal background check). If a second rotation occurs within a 12 month period of the first clinical background checks and health information will not have to be repeated or updated. Must submit to a drug screening within 14 days prior to start of clinical. Must complete an infection control in-service

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered training, emergency procedure training, and an orientation program at facility. Will receive a copy of the Patient Bill of Rights from agency and sign a statement that such copy has been has been received and they understand their responsibilities with regard to patient rights. Must maintain health insurance coverage. Must have an annual TB test while at facility. Must provide documentation of OSHA education. Southern Ohio Medical Center Nurse Practitioner USA Faculty: Must consult with Medical Center on its planned schedule of student assignments, Portsmouth, Ohio including the number and names of student(s), level of academic preparation, and time, length and dates of clinical.

Student: Must complete a negative Urine Drug Screen (min. 5-panel to include: Marijuana, Cocaine, PCP, Amphetamines, and Opiates). Proof of immunity to or signed waiver for Hepatitis B and documentation of a one-time dose of T-dap. Students must comply with such other testing and requirements as Medical Center requires of its employees or as may be required by law. Must have health and accident insurance to cover any and all work related or clinical experience related injuries or illnesses. Student must provide certificate verifying they have received appropriate training in blood and body fluid isolation as required by OSHA to USA and Medical Center. Southwest Health System USA/Faculty: Instruct all students in the confidentiality of patient/client records and these Cortez, Colorado requirements are to survive the termination or expiration of agreement. Must submit all required student information to facility Director Medical Staff Services (Meghan Higman - [email protected]) at least two weeks prior to clinicals. Student name, Drug-free status report, TB Skin Test, Influenza vaccine for current flu season, up-to-date vaccine history, Student: May be subject to drug tests at any time at the initiative and in the sole discretion of facility.

Southwest Public Health District 8, Unit Graduate Nursing Students must sign an Acknowledgement of Confidentiality at the beginning of their placement. 2 (Southwest Georgia Health District) Each participating student is to furnish proof of up- (encompasses clinical facilities in Georgia to-date immunization status, including Hepatitis B counties of Baker, Calhoun, Colquitt, Decatur, vaccination and Annual TB Skin test, the results of Dougherty, Early, Grady, Lee, Miller, Mitchell, which shall, upon request, be made available to the Seminole, Terrell, Thomas & Worth) Agency. Albany, Georgia Southwestern Regional Medical RN-BSN, MSN, USA/Faculty: Please review Exhibit B for Program DNP Specific Requirements. Must provide evidence that Center, Inc. each student has met all requirements of CPR Tulsa, Oklahoma certification, hepatitis B vaccination, and OSHA compliance for prevention of transmission of blood borne pathogens and TB.

Student: Meet the personal, ethical and professional standards required of employees of the facility and consistent with the applicable professional Code of Ethics and the applicable standards of The Joint Commission and/or other relevant accrediting or regulatory bodies.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered

Spartanburg Area Mental Health Nursing USA/Faculty: Notify the Agency of the schedule of student assignment, including name, level of Center academic preparedness, and length and dates of Spartanburg, South Carolina assignment. Contact: Elizabeth Boaze-Nursing Supervisor [email protected] Spartanburg Regional Health Services Agency may require USA Faculty to provide names of students as well as confirmation of various District, Inc. disclosures and /or training requirements. Students Spartanburg, South Carolina must complete Exhibit A. Speare Memorial Hospital Faculty, provide information regarding curriculum and clinical education goals associated with the Plymouth, New Hampshire clinical rotation. Must notify agency within 1 month in advance to change student assignment. Faculty must complete a student profile from the agency to include a picture of the student (for ID purposes) specific dates of the clinical rotation. Students must maintain Health insurance coverage during clinical. Students must have had physical exam prior to beginning of clinical rotation. Spectrum Health System Nursing USA Faculty MUST CONTACT Clinical Affairs for special instructions for an updated background Grand Rapids, Michigan check specifically to Michigan. Agency contact: [email protected] Exhibit A must be completed prior to participation in clinical experience. USA/Faculty: See Exhibit A. Must submit request for student placement at least one month in advance. Include student name, dates for clinical, course objectives and/or course syllabus. Student: Must follow Exhibit A-required immunizations. Spotsylvania Regional Medical Center Graduate USA/Faculty: Completed Exhibit C-Attestation. Nursing Provide to Agency information regarding each Fredericksburg, Virginia Student, including health examination and Program immunization records, documentation attesting to the competency of Degree Program faculty (e.g., state licensure, board certification in the relevant Specialty, etc.) and background checks and drug screens. Each Student submits to a medical examination acceptable to Hospital prior to each Semester Rotation and maintains health insurance and provides proof of health insurance prior to participating in the Clinical Program. Student furnishes to Agency prior to each Semester Rotation a complete copy of the following health records: (Tuberculin skin test performed within the past twelve (12) months or documentation as a previous positive reactor; Proof of Rubella and Rubeola immunity by positive antibody titers or two (2) doses of MMR; Proof of Varicella immunity, by positive history of chickenpox or Varicella immunization; Proof of Influenza vaccination during the flu season, October 1 to March 31, (or dates defined by CDC), or a signed Declination Form; and Proof of Hepatitis B immunization or declination of vaccine, if patient contact is anticipated.

Student: Completed Exhibits A&B.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Springboro Family Medicine (only with MSN, DNP USA/Faculty: Exhibits A-C must be completed by student, Faculty will be the contact person for preceptor, Dr. Dori Thompson) student. Submit all requested student information to Dayton, Ohio facility within 30 days prior to clinicals. Student: Must have satisfactory health status as determined by the standards of the Ohio Dept. of Health CDD and Hospital, as delineated in Exhibit A. Must provide proof of health insurance. Must complete Exhibit A-C. Must continuously maintain RN licensure in the State of ohio during the term of agreement (September 8, 2014-September 7, 2015). Student may not document in either the History & Physical or Discharge Notes portions of said permanent medical record. Springhill Medical Center Undergraduate University is required to provide results of any drug and Graduate or alcohol tests to the Agency prior to a particular Mobile, Alabama Nursing student’s clinical rotation. As an alternative to providing the test results to the Agency, the University may certify the student has been tested and no evidence of drugs or alcohol was found. The Agency may at its sole discretion require a student to undergo drug and/or alcohol testing to continue a clinical rotation at the Agency. SSM Health (will also cover St. MSN, DNP USA/Faculty: Submit upon request student information (names, health status reports, Anthony’s Hospital in OKC and all its immunization records, etc.). subsidiaries) Student: Must complete Exhibit 1-Confidentiality and St. Louis, Missouri Security Agreement. In addition For FACILITY sites in the state of Missouri, Student shall comply with the background check provisions of the regional guidelines for allied health/nursing districts of the St. Louis Metropolitan Hospital Council. (CHI) St. Alexius Medical Center (also Nursing-RN-BSN, Student: Must complete Attachment A&B (Be aware MSN, DNP of #8 on Attachment A). . covers the Minot site) Nurse Practitioner Bismarck, North Dakota St. Bernard’s Medical Center Undergraduate and Graduate Jonesboro, Arkansas Nursing St. Charles Health System Graduate Nursing Student: Must provide verification of completion of an in-person, AHA-approved training program and Bend, OR certification (that remains current though the clinical placement), in CPR/Basic Life Support at the healthcare provider level. Must complete Agency’s site-specific orientation and computer based learning requirements see Exhibit A. Must read and sign the Acceptable Use and Confidentiality Agreement see Exhibit B. Must read and sign the Compliance Program and Code of Ethics Attestation see Exhibit C. Complete and sign the Emergency Contact Information see Exhibit D. St. Cloud VA Medical Center St. Cloud, Minnesota

St. David’s Healthcare Partnership, MSN, DNP, *On-site USA Faculty/Staff must drug/alcohol test* Advanced Practice L.P., LLP (to include: St. David’s Medical Center, USA/Faculty: Must complete Exhibit C-Student St. David’s Rehabilitation Hospital, Heart Hospital of Attestation. Agency contact is Alice Yuan- Austin, St. David’s Georgetown Hospital, St. David’s [email protected] North Austin Medical Center, St. David’s Round Rock

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered medical Center, St. David’s South Austin Medical Student: Must complete Exhibits A & B. Must have Center) yearly medical examination. Austin, Texas St. Dominic-Jackson Memorial (also BSN, RN-BSN, Student must complete Exhibit A. MSN, DNP covers St. Dominic Medical Students cannot have a GPA of lower than 2.0 in the Associates, LLC) nursing curriculum. Must have annual physical Jackson, Mississippi examination. Must have completed a training program for the prevention of the transmission of blood borne pathogens. St. Elizabeth Healthcare Graduate Nursing Faculty: Provide Hospital with advance notice of the Programs dates of the Program, the number of students to be Edgewood, Kentucky enrolled in the Program and the types of experiences desired in the clinical field. Faculty member will inform the students and preceptor of all information, goals, objectives and expectations before the experience begins.

Student must complete Appendix A. Students have the responsibility to obtain health insurance coverage for the entire term of their clinical experience. St. Elizabeth Physicians Group USA/Faculty: Provide advance notice to agency of the dates and number of students and for clinicals Crestview Hills, Kentucky each period. Provide a copy of the student’s schedule indicating holidays and other closures.

Student: Must obtain health insurance coverage for the entire term of their clinical. Must read and sign the Statement of Understanding. St. Francis Hospital NOTE: DUAL * Agreement for Advanced Emergency Nurse ROLE Students Practitioner Students Only* Memphis, Tennessee USA/Faculty: Complete Exhibit C-Attestation.

Students: Must complete Exhibit A-Statement of Responsibility and Exhibit B-Confidentiality Statement. Must have received OSHA training pertaining to exposure to blood borne pathogens in the workplace.

St. Francis Medical Center, Inc. RN-BSN. MSN, Complete Attachment 1,2 and 3 DNP Must go through a mini orientation. (Medical Center and St. Francis Please call the following contact for an appt. Primary Care Clinic) Christina Randle, MHRM Monroe, LA (318) 966-4847 [email protected] St. John Health System, Inc. (to include: Graduate Nursing USA/Faculty: Please provide a roster of student/ St. John Medical Center, Inc., St. John Broken Students faculty names and rotating schedule to agency Arrow, Inc., Owasso Medical Facility, Inc. d/b/a contact: Karen Smith [email protected]. Students must have OSHA training. Please see St. John Owasso, St. John Sapulpa, Inc., exhibit for programs involving research. Jane Phillips Memorial Medical Center, Inc., St. Student: Please provide verification of the following: John Physicians, Inc. d/b/a St. John Clinic, Immunizations OMNI Medical Group, Inc., St. John Urgent Drug test Care Clinics, Inc.) Verification that immunity requirements are met and Tulsa, Oklahoma supported by documentation for: Mumps, Rubella, Rubeola, and Varicella; verification of Hepatitis B vaccination in accordance with recommendations of OSHA; TB test within past 12 months; verification of influenza vaccination or documentation of declination. CPR certification. Background check from state of residency run within 1 year of first clinical at facility.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered

St. Francis Health, LLC Nursing Student must complete Exhibit A-Student Applied Learning Experience Agreement and Exhibit B Columbus, Georgia Supervision of Applied Learning Experience Program (for preceptor if graduate student). Exhibits must be completed at least one month before beginning of the Learning Experience. St. Francis Physician Services/St. MSN and DNP Students. USA Faculty: Francis Hospital Students: Must meet facility’s policy regarding fire Greenville, South Carolina safety and blood-borne pathogen training. Must read the Bon Secours Health System Code of Conduct before reading and signing the student agreement.

St. John Providence Graduate USA/Faculty: Complete Exhibit A. Provide Agency with advance notice of students and faculty involved Detroit, Michigan Nursing Programs in clinicals.

Student: Complete Exhibit B and C. St. Joseph’s /Candler Health System Covered programs are: (Saint Joseph’s Hospital, Inc., SJC Medical Group, Acute Care NP Inc., Candler Hospital, Inc., and SJC Home Health BSN Services, Inc.) Emergency NP Savannah, Georgia MSN FNP Pediatric NP Faculty please see Exhibit A (agency attachments list) Student must have current physical. Students must maintain health insurance with proof to agency being provided upon request. St. Joseph’s Hospital Graduate Nursing Complete Exhibits A-C.

Tucson, Arizona Student’s must view a videotape regarding Hospital’s patient information privacy policies and practices and must achieve a passing score on the questions at the end of the video. https://www.youtube.com/watch?v=QWRn2r5R7ts&i ndex=2&list=PLACD9536723837201 St. Joseph Mercy Oakland Nurse Practitioner USA/Faculty: Provide the names of students who will participate in the Program as soon as possible after Pontiac, Michigan registration for each semester, but in no event later than one week before the beginning of the P Each student provides Agency with the following prior to the start of any clinical rotation at Agency: Tuberculin skin test (must be completed not more than one year prior to start date). The Tuberculin Assessment Form must be completed if previous tuberculin test was positive. If born before January 1, 1957, documentation of measles, mumps, and rubella (“MMR”) titers showing immunity. If non-immune, two MMR vaccinations. If born after January 1, 1957, documentation of two MMR vaccinations. Attestation of having had the chicken pox or varicella titer as showing immunity. Evidence of cardiopulmonary resuscitation (“CPR”) certification and/or skills. Evidence that student has received the Hepatitis B vaccination (or written refusal of Hepatitis B vaccination signed by student that expressly holds

152

UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Hospital harmless for any Hepatitis B exposure or infection that may result from student’s clinical experience at Hospital), proof of immunity to Hepatitis B, and/or such other immunization and health-related testing as may be required by the State of Michigan or OSHA for each student assigned to Hospital, as these requirements may change from time to time. For purposes of this Agreement, student shall be considered to be vaccinated against Hepatitis B if he or she has received at least one vaccine injection and is in the process of completing the required three injection vaccination series. Evidence that student has received the seasonal flu vaccination (between the months of October and April) in accordance with Agency’s policy program at Hospital. Notify the appropriate Agency department at least thirty (30) days prior to the date USA desires to establish a clinical experience for its students. Such notice shall include USA’s overall plan for the use of Agency’s facilities, including the objectives, approximate number of students for each term or semester, dates, times, and levels of each student’s academic preparedness. USA shall again notify the appropriate Agency department one business day prior to the date the clinical experience is scheduled to commence.

Students must complete Exhibit A-Clinical Experience Participation Agreement. St. Joseph Regional Medical Center USA/Faculty: Please complete Exhibit B-Verification of Required Documentation Statement, two weeks (as of June 2017-Capella Healthcare, prior to the beginning of clinicals. Ensure students Inc) have received in compliance with OSHA Blood- Lewiston, Idaho Borne Pathogen Regulations and infection control procedures prior to clinical experience.

Student: Must complete Exhibit C-Student Agreement-Clinical Experience. St. Louis Children’s Hospital Nurse USA/Faculty: Provide Agency with names, St. Louis, Missouri Practitioner health status reports, including immunization Students records before the beginning date of the clinical experience. See Exhibit 2 of requirements.

Students: Must complete Exhibit 1 Must provide evidence of health insurance. St. Luke’s Health System, Ltd. (to Please ask Clinical Affairs for the updated background requirements include St. Luke’s Regional Medical Center – Boise, St. Luke’s Regional Preceptors for Graduate Clinical Rotations at St. Medical Center – Meridian, St. Luke’s Lukes Health System Medical, APRN, NP, CNS, PA Students Magic Valley Regional Medical Center (Twin Falls), St. Luke’s Wood River Are you looking for a preceptor? You must submit your request soon! Medical Center (Hailey-Ketchum), St. Luke’s McCall - McCall, St. Luke’s Important Notes on Clinical Placement: Eagle Medical Plaza Mountain States • All graduate student clinical placement requests must be scheduled and confirmed through Tumor Institute, St. Luke’s Clinics, St. Student Services and Academic Planning

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Luke’s Jerome-Jerome, St. Luke’s • A current affiliation agreement must be in place between your university and St. Luke’s. To Elmore – Mountain Home confirm if there is an agreement please contact Boise, Idaho Lydia Carbis at [email protected] or call 381-1503 • ACP will work diligently to secure placement for requested rotations. Placement is not guaranteed. • A schedule for application due dates is indicated below. Applications received by the deadline will receive priority however, placement is always made based on the best fit for the student and available preceptors. • St. Luke’s staff who have identified potential preceptors should indicate the providers name on their application. ACP will confirm the rotation with the provider.

Submit your Request Online:

APRN, PA, NP, CNS students go to:

https://www.surveymonkey.com/r/SLHSrequestforpla cement

Requirements must be met by ALL students before they begin their clinical experience.

1. Background check

2. Current immunizations/vac cinations

3. Liability insurance

4. Personal health insurance

Faculty will contact agency no less than 30 days prior to clinical in order for St. Luke’s to determine capacity. At least 15 days prior to clinical Faculty must provide student information and documentation to facility. Students must complete Attachment B. Agreement covers all Nurse Practitioner and Nursing Programs. Must have Flu vaccination, exemption only for strongly held religious beliefs and medical reasons. St. Luke’s Medical Center and Tempe Graduate Nursing Students: Agree to pay the Hospital the sum of $75 Programs per week for each clinical learning experience St. Luke’s Hospital, Mountain Vista completed at Hospital. Must complete Exhibits A&B. Medical Center and St. Luke’s Behavioral Health Center (IASIS) Phoenix, Arizona St. Luke’s University Health Network Nursing Faculty: (to include locations at: 801 Ostrum St. MSN Complete Exhibit 2 (Request for Clinical Education DNP Student Rotation). Faculty and Agency will agree to Bethlehem, 1736 Hamilton Blvd. the number of students, their schedule and dates of Allentown, PA, 1872 Riverside Circle, admission at least (6) six weeks prior the date of Easton, PA, St. Luke’s Quakertown admission. The specific days and hours of the

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Hospital, St. Luke’s Miners Memorial student’s activities at St. Luke’s Health System will Hospital, Visiting Nurse’s Assoc. of St. be mutually agreed upon by both parties. Faculty will complete the Request for Clinical Luke’s, Home Health/Hospice, Inc. and St. Education Student Rotation, Exhibit 2.. Luke’s Physician Group, Inc.) Students: Pennsylvania Background Check: Student must complete and submit to agency the following: a. Student registration form. b. Student statement of responsibility. c. Student must maintain and provide evidence of current CPR certification for the duration of clinicals. d. Students shall be responsible for maintaining health insurance coverage while in clinicals. Drug Screen: Must have a clear 5 panel urine drug screen test administred by an HHS-certified lab to include: 1.amphetaphines, 2.cocaine, 3.cannabinoids, 4.opiates (including morphine, codeine, hydromorphone, and hydrocodone) and 5. phencyclidine. Drug Screen Test: Drug Test must be administered no earlier than 30 days prior to the date of beginning clinicals. Such other health related information and/or testing as may be requested by St. Luke’s Health System from time to time. Faculty and Students: * Administration of such test shall be required prior to student's first assignment at PROVIDER. If a student maintains continuous enrollment at SCHOOL and participates in a subsequent rotation at PROVIDER, and SCHOOL provides a written statement to PROVIDER prior to such subsequent rotation that it has no reason to believe that the student has not continued to be drug free, safe and qualified for the clinical experience under this Agreement, then such test will not be required for the subsequent rotation. If no such statement is provided by SCHOOL, such test will be required prior to the subsequent rotation.

Background Screening must be dated no earlier than 24 months prior to first date of clinical.

Health Requirements: No active Tuberculosis, as evidenced by two tuberculin skin tests showing either (a) a negative result, (demonstrated by either the last two consecutive annual TB skin tests dated within two (2) years of the date of assignment at St. Luke's OR two step TB testing - two tests dated within one (l) year of date of assignment at St. Luke's) or (b) if a positive result, additional completion of a TB symptom questionnaire AND negative chest x-ray or BAMT Blood Assay Mycobacterium Tuberculosis test done no earlier than three (3) years prior to the date of assignment at the PROVIDER. History of BCG administration without TB testing is NOT acceptable. St. Mary’s Health, Inc. RN-BSN, MSN, USA/Faculty: Notify Facility of the number of DNP students and rotation periods four weeks prior to the

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Evansville, Indiana commencement of the clinical experience. Forward students' full legal name, full social security number, date of birth, permanent mailing address, phone number and email address on behalf of the student or notify the student the clinical facility must have this information no less than 72 business hours prior to clinical experience. Provide to Facility, statement of philosophy and the objective of curricular and clinical education. Student: Must have general background and training in blood borne pathogens and infection control according to OSHA standards and Hazardous Materials Awareness prior to clinical experience.

St. Mary Medical Center USA must provide agency with student names at least 30 days prior to beginning of clinicals. USA Langhorne, PA must have written agreement with Physician (whom is to have active privileges at agency), and copy must be provided to agency. St. Mary’s Health Care System RN-BSN, MSN, USA/Faculty: Provide written plans for the Athens, Georgia DNP Learning Experience and Student assignments to Agency no less than 30 days prior to the beginning of clinical. Submit to: Kimberly Lawrence. Clinical Education Department 1230 Baxter Street, Athens, GA, 30606, 706- 389-2150, [email protected]. Student: Submit the Orientation packet (provided by Agency) to Agency at least one week prior to clinical. St. Mary’s Hospital & Medical Center, MSN, DNP USA/Faculty: Please complete Exhibit A and submit to agency at least 3 weeks prior to clinicals. Agency Inc. contact: Pat Montgomery- Grand Junction, Colorado [email protected]. USA Faculty must receive waiver from Agency in writing Renewal in process-set to expire on regarding their orientation program. Must notify 9/6/2018 Agency of any change in Program Faculty at least two weeks prior to the start of clinicals. Student: Must provide proficiency in written and spoken English language. Provide Agency with documentation of training in OSHA (including blood borne pathogens), Universal Precautions as defined by the Center for Disease Control and Prevention, and CPR Cert. Must have health insurance. St. Mary’s Medical Center Graduate Nursing USA/Faculty: Please see Exhibit C-Attestation. Programs Agency contact for student inquiries is Karen Boyler West Palm Beach, Florida [email protected] Student: Must complete Exhibits A&B. Must provide evidence of, without limitation the completion of a two-step tuberculin skin test (within the last six months) or evidence that each Program Participant is free of symptoms of pulmonary disease if the skin test is positive, a chest x-ray following a positive TB test result, negative drug screening, physical examination, proof of rubella, and rubeola immunity by positive antibody titers or 2 doses of MMR, and evidence of completion of the series of three hepatitis B vaccinations (if required by applicable law or Hospital policy). Prior to a student’s first assignment at Hospital, it’s required that the individual view a videotape regarding Hospital’s patient information privacy policies and practices (available through the Internet at

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered https://www.youtube.com/watch?v=QWRn2r5R7ts&i ndex=2&list=PLACD9536723837201), in its entirety and achieve a passing score (as defined by Hospital from time to time) on the questions at the end of the Video.

St. Mary’s Physician Services, LLC USA/Faculty: Must require each Program Participant to sign a Statement of Responsibility (exhibit A) and d/b/a Millard Henry Clinic a Statement of Confidentiality (exhibit B). Russellville, Arkansas Student: May be required to submit to a medical examination prior to beginning clinicals.

Background Checks/Drug Screening. School shall inform students and/or staff/faculty of Hospital’s requirement, that prior to the first day of their educational experience at Hospital, Hospital will conduct (or have conducted), at the Program Participant’s expense, a background check and drug screening on each Program Participant and every member of the staff/faculty (if any participating on- site) responsible for supervision and/or instruction. Drug screening must be conducted within the thirty (30) day period prior to the Program Participant’s first day of their educational experience at Hospital. Payment for the background check and drug screening will be required in advance of the Hospital conducting the background check and drug screening. If School has students or staff/faculty on-site at Hospital prior to the execution of this Agreement, then Hospital shall immediately conduct a retrospective background check on such persons and such persons shall submit to a drug screening, at the Program Participant’s and or staff/faculty’s expense (payable in advance). The background check for all students shall include the following: (i) Education verification (highest level); (ii) Professional License Verification; (iii) Criminal Background and Sex Offender Registry; (iv) Professional Disciplinary Action Search; (v) Department of Motor Vehicle Driving History, based on responsibilities; (vi) Consumer Credit Report, based on responsibilities. Should the background check/drug screening disclose adverse information as to any student and/or member of the staff/faculty, School shall immediately remove said student and/or member of the staff/faculty from participation in all Programs at Hospital. St. Tammany Parish Hospital BSN, RN-BSN, USA/Faculty: Provide Agency with a roster of MSN, and DNP Covington, Louisiana students, clinical practice assignments, scheduled rotations, and a brief resume of the course outline and objectives for the learning experience.

Each student must be free of contagious infection/disease. A health statement must include (1) results of a negative TB skin test within the past twelve months or documentation of a previous positive result and annual counseling

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered to determine communicability; (2) rubella/rubeola immunity or proof of immunization; (3) verification by history of chicken pox or written documentation of immunity or receipt of varicella vaccine; and (4) evidence of Hepatitis B vaccine or a written refusal. Students and faculty assigned to the facility have received flu immunizations prior to December 15th of each year St. Vincent Healthcare Faculty please complete the clinical request form (Exhibit A). At least 3 weeks prior to clinical provide Billings, Montana student names and information to hospital including, criminal background checks, drug screens, immunization record, and proficiency in written and spoken English language. Obtain hospital’s prior written approval before publishing any material relating to the Program’s or Student’s participation. Students must provide and pay for their own Worker’s Compensation while at the Hospital. Students will not participate in any of Hospital’s insurance programs or benefit program’s to include Worker’s Compensation. St. Vincent’s Health System (to include: BSN, RN-BSN, Please see required additional documents per St. Vincent’s Birmingham, St. Vincent’s East, RN-BSN/MSN, the agreement Exhibit B&C. Contact: Terry BSN-DNP,MSN, St. Vincent’s Blount, St. Vincent’s St. Clair, St. Wilson - (205) 838-3992 (office)- MSN-DNP, DNP [email protected] Vincent’s Chilton, One Nineteen, American Nurse Practitioner Sports Medicine Institute, and any affiliated St. Vincent’s Clinics) Birmingham, Alabama St. Vincent’s Health System (to USA/Faculty: Obtain an agreement of a Medical Staff Physician to assume responsibility of student. include: St. Vincent’s Medical Center- Provide names of students, and the days and hours Southside, St. Vincent’s Medical of assigned clinical. Center-Clay County) Student: Submit documentation of all requirements to facility. Must complete Orientation Guide available Jacksonville, Florida from facility. Complete Exhibit B-Confidentiality Agreement. St. Vincent Hospital d/b/a Prevea Nursing USA Faculty: See Exhibit C for requirements. Must submit schedule indicating the number and names Health (covers; St. Vincent Green Bay, of students who will be participating and name of the St. Mary’s Hospital Medical Center- faculty three weeks prior to clinicals. Students must Green Bay, St. Nicholas Hospital, St. satisfy agency’s requirements for background checks and drug screening. Clare Memorial Hospital, Prevea Health Clinic -all sites) Green Bay, Wisconsin St. Vincent Infirmary Health System Students must complete Exhibit A prior to beginning clinicals. Little Rock, Arkansas St. Vincent’s Medical Center, Inc.- USA/Faculty: Must provide a list of students being assigned to facility in a timely manner. Complete Riverside Educational Institution Verification Letter Jacksonville, Florida Student: Must have documentation of negative TB skin test within six months prior to clinicals. Must participate in Facility’s quality and risk management programs as required. Must complete required orientation guide. Must sign the Confidentiality Agreement prior to clinicals. Stanford Health Care/ValleyCare BSN, RN-BSN, MSN, DNP

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Pleasanton, California Renewal in process-set to expire 12/31/2018 State Hospital South Nursing Programs USA/Faculty: Provide a statement or copy of goals, objectives and schedule. Blackfoot, Idaho Students: Must complete and submit the Agency’s orientation packet prior to clinicals. Available from the Agency. Steward Medical Group Nursing USA/Faculty: Complete Clinical Request Form and submit to Sebastian, Florida (Boston, MA Main Janet Pellizze [email protected]. See Office) Exhibits A&B-Criminal Background Check Policy and Health Related Documentation. Provide a copy of current information about the curriculum and clinical education goals prior to the start of each student’s clinical experience.

Student’s will also be required to complete student orientation with SRMC before starting either clinical with the hospital or clinic. Steward Sebastian River Medical Nursing USA/Faculty: Complete Clinical Request Form and submit to Center Janet Pellizze [email protected]. See Sebastian, Florida (Boston, MA Main Exhibits A&B-Criminal Background Check Policy and Office) Health Related Documentation. Provide a copy of current information about the curriculum and clinical education goals prior to the start of each student’s clinical experience.

Student’s will also be required to complete student orientation with SRMC before starting either clinical with the hospital or clinic. Stone County Hospital Nursing USA/Faculty: Complete Exhibit C-Attestation. Students: Completed Exhibits A&B. Must provide Wiggins, Mississippi evidence of Health Insurance coverage. Renewal in process-set to expire 7/11/2018 Suburban Hospital (Johns Hopkins) Nursing USA/Faculty: Complete Exhibit A (2 pages) for each student placement. See Exhibit A-requirements. Baltimore, Maryland Exhibit D-Is for on-site supervising Faculty only.

Student: Must complete Exhibit B and C.

Please note: Ownership of Works; Publications. Any written or virtual works, ideas, concepts, designs, processes, algorithms, and other outputs developed by Students, Hospital, or a combination thereof developed as a part of a Student’s responsibilities during the Hospital Placement (referred to collectively as the “Works”) shall be the sole property of Hospital. Neither Student nor School shall disclose or use any such Works for any purpose other than evaluation of the Student’s performance without Hospital’s prior written approval. To the extent that Students and/or Faculty work cooperatively with Hospital on a publication, authorship will follow established guidelines for professional works. Neither School, Faculty nor Students shall publish any materials related directly

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered or indirectly to a Student’s placement at Hospital without Hospital’s prior written consent. Summa Health System Hospitals Graduate Nursing Students: Shall be required to have immunizations as appropriate: Akron, Ohio EMPLOYEES ONLY EFFECTIVE Screening for TB via either ICRA blood test or PPD 2/22/2018 skin test (2-step if initial test) Evidence of Tdap booster Evidence of 2 doses of MMR vaccine or immunity by Renewal in process-set to expire titer Evidence of 2 doses of Varicella (chicken pox) 9/1/2018 vaccine or Varicella immunity evidence by titer or history of illness Hepatitis B vaccination, if required Influenza vaccination annually--must be vaccinated to be in any FACILITY Building from November 1st to end of flu season

While the start of the flu season is generally November 1, the actual start and end of the flu season for any particular year is determined in the sole discretion of FACILITY’s Manager of Infection Control. Students must maintain health insurance while at facility. Criminal Background Check must go back seven years.

Summa Physicians, Inc. Students: Must maintain health insurance and provide proof of such insurance to agency. See Akron, Ohio attachment for agency immunization requirements. Sunrise Hospital and Medical Center Advanced Practice SUNRISE EMPLOYEES ONLY Student Only (they Student- Complete Exhibits A & B. Must pass a Las Vegas, Nevada include DNP in medical examination at least once a year prior to SUNRISE EMPLOYEES ONLY this category). clinicals. USA/Faculty- Complete Exhibit C-Attestation Please double check that this is the updated Exhibit C. Swedish Health Services Nursing Programs USA/Faculty: Must use Clinical Passport- Seattle, Washington See Clinical Passport Requirements. all students complete all OSHA/WOSH training available via Clinical Placements Northwest (“CPNW”) or Swedish Health Services (e.g. risks and hazards in the environment, hazardous materials communications, and work place violence), medical surveillance, immunizations, and record keeping required for Bloodborne Pathogens (including Hepatitis B Vaccine and post-exposure follow up). Training is required prior to student or faculty participation in clinical activities at Swedish Health Services. Documentation verifying such training must be presented upon request. SWLA Center for Health Services Undergraduate Lake Charles, Louisiana and Graduate Nursing

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Take Care Health Systems, LLC NP NP STUDENTS

Conshohocken, Pennsylvania Faculty may need to send clinical program letter to agency, outline available from Contract Office. Students: Name tags must be clearly visible and worn at all times while at the facility. Student must notify agency prior to scheduled start time if the student will be absent from scheduled participation in the Clinical Program. Tallahassee Medical Center, Inc., Nursing Program must be approved by hospital prior to clinicals. Students must complete Exhibit A & B. Capital Regional Medical Center Attestation form (Exhibit C) must be completed. Tallahassee, Florida

Tallahassee Memorial HealthCare, MSN, DNP NP STUDENTS

Inc. Students must sign a Prohibition of Voluntary Tallahassee, Florida Participation in Legal Action Against TMH document: which prevents the student from ever Renewal in process-set to participating in any legal action against TMH. expire 7/31/2018-Program Students should carefully consider their rights before signing. Agreement. Students: Name tags must be clearly visible and worn at all times while at the facility. Student must notify agency prior to scheduled start time if the student will be absent from scheduled participation in the Clinical Program.

Tampa General Hospital (Florida MSN, Emergency Contract only to be used as a 3-way Health Science Center and Florida NP, Acute Care agreement with Tampa General/Gulf NP Gulf to Bay) (Florida Gulf to Bay to Bay/University of South Alabama Anesthesiology Associates, PA) Tampa, Florida Tampa General Hospital and MSN and DNP USA/Faculty: Student and Faculty must comply with all University of South Florida applicable Hospital policies and procedures on Tampa, Florida immunizations and communicable diseases as more fully described in the "Employee Health Services Guidelines for Students in Patient Care Areas." Provide the following information: Student: Annual TB skin testing, be vaccinated for Hepatitis B or sign a release if declining that vaccination. Required to get a Tampa General Hospital badge from the hospital HR department/return badge upon completion of clinicals.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Tampa General Hospital BSN, MSN, and Agency Contact: Tabitha [email protected] 813- DNP Programs 844-7235. Tampa, Florida Students and Faculty must comply with all applicable policies and procedures as outlined in Exhibit B: Employee Health Services Guidelines for Students in Patient Care Area.

USA/Faculty: Number of students to be agreed upon 30 days in advance of any student's clinical experience. Provide facility with the name(s), dates, and hour of clinical experience and academic class designation of student. Report to Clinical Affairs the following information if a student was assigned to TGH during 10/1-3/31. # of students assigned during time frame. # of students assigned that received flu vaccine. # of students assigned that had medical contraindications to flu vaccine and had to wear a mask while in a clinical experience at TGH.

Students: Must have Hepatitis B vaccine or sign a release if declining the vaccine. Required to get a Tampa General Hospital badge from the Hospital HR Department at the start of their clinical experience. Badge must be worn above the waist at all times while on the TGH Campus and returned to the HR Department at the end of their clinical experience. Tanana Chiefs Conference MSN, DNP USA/Faculty: Provide Program Description to facility. Facility Contact: Annita Clark - Fairbanks, Alaska [email protected], ext. 3704. Student: Must have a criminal background check under the Indian Child Protection Act (IPCA) through the facility.

Tanner Medical Center, Inc. Nursing USA/Faculty: Provide names of students to agency. Student: Criminal background check completed within (includes Tanner Medical Group) 12 months prior to clinical experience. Current physical Carrollton, Georgia exam and drug screen. Fingernails and artificial nails: Direct caregivers and food/nutrition service workers will not be permitted to wear artificial/acrylic fingernails or extenders. Keep natural nail tips less than 1/4-inch long. Contract Company MSN, DNP Must also have an agreement with Facility where clinical experience will take place. Team Health West (THW) Agency Contact: Andrea Lowe-713-932-5803- Emergency Management of [email protected] Houston, LLC-Huntsville USA/Faculty: Provide Company and Preceptor with an orientation to course objectives, schedule of each Houston, Texas student assignment, name of student, level of academic preparation, length and dates of assignment. Team Health West Region Undergraduate Moore, Oklahoma and Graduate Nursing

Tennessee Valley Healthcare MSN System (All-Sites) Nashville, Tennessee Terrebonne General Medical Nurse Practitioner USA/Faculty: At least 3 weeks prior to Program Center Programs semester, provide Agency with a roster of the name of student, term of each semester,

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Houma, Louisiana specialty, and estimated number of hours, name of preceptor who will be supervising student.

Student must have Agency issued ID Badge. Request must be made at least 3 weeks prior to clinical experience. Health insurance coverage for student if covered; Negative drug screen; Valid criminal background check; Proof of MMR; Hepatitis B vaccine; Negative TB/PPD skin test or Negative chest X- ray; Proof of Varicella vaccine; if no history of chicken pox; Current certification for CPR; Evidence of training and education in occupational exposure to blood borne pathogens, protective practices to avoid contamination, and procedures for decontamination in case of exposure to infectious materials; Completion of TGMC orientation process; and Verification of licensure and certifications of students and instructors.

Terry Reilly Health Services BSN, RN-BSN, USA/Faculty: Must submit to agency a minimum of four MSN, DNP weeks prior to the beginning of clinical a schedule Nampa, Idaho indicating the number and names of students, name of preceptor and USA faculty. Copy of student’s immunization records must be provided to agency. Student: Must complete the State of Idaho Department of Health and Welfare criminal background check prior to beginning of clinicals.

Texas Children’s Health Plan The Nurse Practitioner USA/Faculty: Provide Facility with a copy of students Students Only course curriculum and learning objectives at the time of Center for Children and Women request for clinical placement. Contact Tori- Houston, Texas [email protected] 832-828-1556 for placing students.

Student: Must carry and maintain health care insurance. Must sign a confidentiality agreement prior to clinicals, provided by agency. Must complete any orientation/training required by agency. Texas Children’s Pediatric (TCP) Acute Care Pediatric USA/Faculty: Provide Facility with a copy of Nurse Practitioner Houston, Texas students course curriculum and learning Students Only objectives at the time of request for clinical placement.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered

Students must possess an RN license and maintain a current and valid license to practice in the State of Texas. Students must carry health care insurance. Students must sign a confidentiality agreement (provided by agency) prior to the start of clinicals. Texas Health Harris Methodist Advanced Practice NOTE: Hospital Southwest Fort Worth and Agreement only covers Dr. Nghi as preceptor. Dr. Minh Q. Nghi USA/Faculty: Provide to Facility at least two weeks Fort Worth, Texas prior to clinicals, a letter outlining the needs of students, days and hours students will be on patient units or service areas, names of students and supervising faculty members, length and dates of clinical experience, and Texas nursing registration numbers of on-site faculty.

Student: Must be tested annually for tuberculosis. If working in the laboratory, students must have documentation that Meningococcal vaccine has been administered. Provide information to each student on the Hepatitis B vaccine, its efficacy, safety, method of administration and benefits of being vaccinated and suggest that students be vaccinated for Hepatitis B; Confirm students have been tested for tuberculosis within one (1) year of commencement of the Program and are tested at least annually while participating in the Program and provide evidence of such testing and the results to Facility prior to commencement of the Program or upon request of Facility. Confirm students have documentation that MMR, Tdap, and varicella vaccinations have been administered and existence of sufficient titers, and each student has a flu vaccine within one year of commencement clinical placement. Confirm students have documentation that Hepatitis A vaccine series has been administered if students are in the following departments: psychiatric departments or facility and nutritional services; Confirm that the name of any assigned students do not appear on either the Health and Human Services (HHS) – Office of Inspector General (OIG) List of Excluded Individuals/Entities, or the General Services Administration List of Excluded Parties or the Texas Medicaid OIG Sanctions List. Facility reserves the right to re-screen students who have access or will be granted Access to protected health information of Facility's patients or confidential information. Texas Health Harris Methodist Advanced Practice (if Contact: Roshonda Helm- preceptor is [email protected]. Hospital Fort Worth and Pediatrix employed by USA/Faculty: Provide to Facility and Group at least 2 Medical Services, Inc. Pediatrix) weeks prior to clinical experience a letter outlining the Fort Worth, Texas (3 way needs of students, days, and hours students will be on patient units or service areas, names of students, and agreement) supervising faculty members, length and dates of clinical experience, and Texas nursing registration numbers of faculty. Student: Background check must include last 10 years. Must complete Exhibit A. Must have been tested for tuberculosis within one year of entering

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered program and must be tested annually while in the program. Must have flu vaccine within one year of clinical experience. Texas Health Physicians Group USA/Faculty: Agency contact-Stephanie Stewart- [email protected]. Dallas, Texas Provide Faculty contact name and contact information Set to expire 8/27/2017, agency to facility. Provide Letter to Facility at least 2 weeks prior to clinical, outlining the needs of students, days will not renew at this time. and hours students will be on patient units, names of students and supervising faculty members, length and dates of clinical experience and Texas nursing registration numbers or credentials of on-site faculty.

Student: Must be tested within one year of commencement of Program and tested at least annually while participating in the Program. Provide evidence of such testing. Upon Facility's request student will submit to a drug test and agree to have the results made available to Facility. Must complete Exhibit A-Student Confidentiality Agreement.

Texas Health Presbyterian Advanced Nurse USA/Faculty: Practitioner Provide to Agency at least two (2) weeks prior to Hospital Dallas-Texas Medicine Dr. commencement of the Program a letter outlining the Sprueil needs of students, days and hours students will be on Dallas, Texas patient units or service areas, names of students and supervising faculty members, length and dates of clinical experience, and Texas nursing registration numbers of faculty

Students: Students have been tested for tuberculosis within one (1) year of commencement of the Program and are tested at least annually while participating in the Program and provide evidence of such testing and the results to Agency prior to commencement of the Program or upon request of Agency. Confirm students have documentation that Hepatitis A vaccine series has been administered. If students are in the following departments: psychiatric departments or Agency and nutritional services. if working in the laboratory, confirm students have documentation that the meningococcal vaccine has been administered. Background check must include: Social Security Number Verification (and trace to verify the individual correlates with the SSN); Criminal background search for a minimum of seven (7) years and of all counties in and outside of Texas in which the Employee has resided or been employed; Employment verification to include reason for separation and eligibility for rehire; Sex Offender Registry; OIG List of Excluded Individuals/Entities; GSA List of Parties Excluded from Federal Programs (with a negative finding); U.S. Treasury Terrorist List (with a negative finding); Applicable State Exclusion List (Medicaid); Office of Foreign Assets Control (OFAC); Previous Address Locator Texas Health Resources (covers: CNL, DNP, MSN USA/Faculty: Please see all required onboarding Texas Health Arlington Memorial Hospital, and Nursing documents.

Texas Health Harris Methodist Hospital

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Fort Worth d/b/a Texas Health Ben Hogan Confirm students have been instructed in Standard Sports Medicine Precautions recommended by the CDC. Provide two Texas Health Harris Methodist Hospital weeks prior to beginning of clinicals, a letter outlining Alliance, Texas Health Presbyterian the needs of students, days and hours students will be on patient units or service areas, names of students Hospital Allen,Texas Health Harris and supervising faculty members, length and dates of Methodist Hospital Azle, Texas Health clinical experience. Agency Contact: Kesha Jackson, Presbyterian Hospital Dallas, Texas Health Education Coordinator-682-236-6187- Harris Methodist Hospital Cleburne, Texas [email protected]. Health Presbyterian Hospital Denton, Texas Health Harris Methodist Hospital Students: Approval from the preceptor’s Fort Worth (including Texas Health manager/director should be communicated to the entity Burleson), Texas Health Presbyterian Academic partnership specialist. An email from the manager is acceptable. Hospital Kaufman, Texas Health Harris Please allow at least 2-3 weeks for student processing. Methodist Hospital Hurst-Euless-Bedford, Prior to student’s arrival, an attestation letter from the Texas Health Presbyterian Hospital Plano students program is required, indicating dates of (including Texas Health Prosper), Texas student’s clinical experience, total number of hours at Health Harris Methodist Southwest Fort the THR facility, and the name of the supervising Worth (including Texas Health Clear Fork), faculty member. Additional requirements for the Texas Health Seay Behavioral Health attestation letter are listed below. Hospital Plano, Texas Health Harris At the conclusion of the clinical experience, the student should confirm the total number of hours spent with the Methodist Stephenville, Texas Health preceptor. This information needs to be communicated Springwood Behavioral Health Hospital to the entity Academic Partnership specialist HEB Alethea McCray-Mayberry Arlington, Texas [email protected] Please return the ID badge application. Contact Sheila McBride to schedule your badging appointment [email protected]

Checklist of onboarding requirements Letter of Attestation: HEP B TB (within 1 year) BLS card MMR Varicella TDAP Flu Vaccine (Flu season) Criminal background history Drug test/screeen Registration into THR student portal http://register.texashealth.org The student is provided with instructions for registering in the student portal. Please include in the comments field whether access to CareConnect is needed their student role. Completion of DFWHC Foundation exam Grading criteria: 100% Required documentation THR Student confidentiality agreement ID badge application (if applicable Texas Tech University Health NNP Faculty must complete Faculty of Record/Coordinator Credentialing form and Pre-Clinical Clearance Form Sciences Center, Paul L. Foster prior to students beginning clinicals. Faculty please School of Medicine, Department of contact Patty [email protected] Pediatrics for onboarding forms. El Paso, Texas

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered The Baton Rouge Clinic, AMC Faculty: Agency requests student specific statement of liability letter be sent to them (contact the USA Baton Rouge, Louisiana Contracts Office)

Faculty must verify annually that the student has : TB skin Test (annually) Up to date Immunization History Criminal Background check for the past 7 years including Residency History Nationwide Database with Sex Offender Index and Healthcare Fraud & Abuse Social Security Alert Urine Drug Screen Faculty, please ask Contract Office for Credential/Administrative Sheet. The Christ Hospital USA/Faculty: Submit in writing to agency the name and academic credentials of person responsible for the Cincinnati, Ohio clinical education program, number of students, dates, and length of clinical (agency contact info: Christina Diekman - 513-585-2154 [email protected]). Student: Must complete the Confidentiality and Data Security Agreement. Must have coverage under a policy of health insurance. Complete Exhibit A - Confidentiality and Data Security.

The Heart Hospital Baylor Plano DNP USA/Faculty: See Exhibit A for clinical requirements. Provide requested information at Plano, Texas least 10 days prior to clinical experience. Student: READ THOROUGHLY and complete Exhibit B. The Queen’s Medical Center USA/Faculty: Provide facility with an updated Honolulu, Hawai’i copy of the program curricula and objectives. Student: Shall provide their own identification tags and uniform.

The Medical Center, Navicent MSN, DNP USA Faculty and Students: Please see and read the 2016 updated instructions and attachments for Health and Navicent Health requirements per the agreement. Physician Group (formerly Medical Center of Central Georgia) Macon, Georgia The Pediatric Group, LLP Graduate Nursing Davidsonville, MD Programs The Physician’s Group, LLC Undergraduate and Graduate Nursing Edmond, Oklahoma Programs The Portland Clinic, LLP Undergraduate and Agency Contact: Portland, Oregon Graduate Nursing Patty Wu Students [email protected] The Private Diagnostic Clinic, Nurse Practitioner USA/Faculty: See Exhibit A for the plan of placement form. PLLC Durham, North Carolina Student: Must sign Confidentiality Agreement provided by the agency. The Toledo Hospital MSN Toledo, Ohio

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered The University of Texas Medical Provide names of students assigned to facility to UTMB Contact: Kathy Angel [email protected] Branch at Galveston (UTMB Health) Galveston, Texas Renewal in process-set to expire 11/1/2018

The Villages Health BSN, RN-BSN, The Villages, Florida MSN, DNP Renewal in process-set to expire on 9/18/2018

The Washington University (School Nursing or Nurse All requests made by COLLEGE for student of Medicine and its controlled affiliates) Practitioner Program placements at INSTITUTION must be in writing St. Louis, Missouri thirty (30) days prior to the start of the clinical rotation and include the following information:

* Type of unit on which placement is requested. * Number of STUDENTS to be placed * Names of STUDENTS. * Desired specific dates and time of placement, including days of week and hours to be on units. Students must maintain health insurance and provide proof of insurance.

Provide written evidence of either a negative TB skin test within the past three (3) months, or a chest x-ray with no evidence of active TB (within one (1) year), in the event of a positive TB skin test.If born on or after January 1, 1957, provide written documentation of two (2) live measles (rubeola) vaccines given no less than one month apart, after the first birthday; or written documentation of laboratory evidence of immunity to rubeola: date and result; or written documentation of physician diagnosed rubeola infection. Provide written documentation of varicella (chicken pox) titer drawn from a reputable laboratory: date and result; or written documentation of two (2) varicella vaccines given no less than one month apart. (Note: in the event of an exposure, prior vaccine recipients will be required to have a titer drawn).Provide written documentation of a completed series of Hepatitis-B vaccines or provide documentation of having begun the series, or provide written documentation of positive surface antibodies to hepatitis B, or documentation of informed refusal of the vaccine. Provide written documentation of laboratory evidence of immunity to rubella (German measles): date and result or written documentation of vaccination or rubella. Provide

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered written documentation of a tetanus/diphtheria booster given within the last ten years. The Woman’s Hospital of Texas MSN, DNP USA/Faculty: Complete Agency's Attestation-Exhibit C. Student: Must complete Exhibits A & B. Houston, Texas The Women’s Hospital BSN, MSN, DNP USA/Faculty: Provide Influenza vaccination status upon request. (Deaconess) Newburgh, Indiana ThedaCare, Inc. RN-BSN, MSN, USA/Faculty: Provide timely and accurate DNP information to Facility regarding the Program, including Appleton, Wisconsin the specific goals and objectives of curriculum. Completed final placement form from the school, validating the student has met the pre-placement requirements available from facility..Only submit the Student/Faculty request form in Excel format, to [email protected] Must keep record of completed Background Information Disclosure (BID) forms on file with USA. Do not send to agency.

Student: Must have a caregiver background check in accordance with the Wisconsin Caregiver Background Check statutes (Wis. Stats. 48.685 and 50.065). Must obtain and maintain health insurance coverage.

Thibodaux Regional Medical MSN, DNP USA/Faculty: POI - Christi Callahan- [email protected]. Background check Center (Thibodaux Women’s must be available to agency during a 24 hour notice Center is covered by this during the work week. Adhere to the rules and agreement) regulations of the agency's Code of Conduct and Ethics manual, if applicable. Thibodaux, Louisiana Student: Must complete student orientation. Adhere to the rules and regulations of the agency's Code of Conduct and Ethics manual. See agency for copy. Tidelands Health (covers all physical MSN and DNP USA/Faculty: Advance notification of clinical locations under Tidelands Health, Tidelands assignments including requested start date, hours, Health Georgetown Memorial, Tidelands Health number of Students and types of experiences sought Waccamaw Community, Tidelands Health Next no later than two weeks prior to assignment in Step Rehab, Tidelands Health Group, Tidelands appropriate format requested by Agency. Health Imagine Center, and Tidelands Health Cancer Center) *Background and Drug Screen, must have been completed within 120 days of admission to the South Murrells Inlet, clinical sequence. Unless student is an employee South Carolina verified by Tidelands Health HR.*

Must provide a letter of good standing.

Students assigned to Tidelands Health are required to present proof (records) to Tidelands Health Employee Health unit indicating a minimum of the following completed :

Proof of Varicella titer or two step Varivax vaccinations or Physician Documentation of Disease. Two step PPD administered Proof of two step MMR vaccine or titer evidence of MMR. Proof of three step Hepatitis B series injections or positive antibody titer or vaccination waiver. Proof of 9 panel drug screen within a (60) sixty day window in advance of start date of clinical rotation.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered If the Student is a current employee of Tidelands Health and is verified though Human Resources the Student’s requirement to produce a (60) sixty day drug screen is waived. Provide notification to all Students and Instructor who seek to participate in a clinical rotation experience with Tidelands Health of the requirement to abide by the Tidelands Health Drug Free and Tobacco Free workplace policies. Proof of seasonal Flu vaccination before clinicals occur during the “Tidelands Health designated flu season”. This season is estimated to run September to May but will be adjusted annually based on CDC recommendations, current local conditions and availability of vaccinations. Tidewater Physicians Nurse Practitioner A copy of the below mentioned liability MUST be Students Only provided to the Agency and the USA Clinical Multispecialty Group, PC Affairs Department (Beth Collier) before the Newport News, Virginia student begins their clinicals.

Student maintains full professional liability insurance, through an occurrence policy with minimum limits of $2,350,000 per occurrence (or such higher amount not less than the liability limitation amount established for health care providers pursuant to the Virginia Medical Malpractice Act or similar legislation, as amended and in effect from time to time) and annual aggregate limits not less than three (3) times the per occurrence limit to cover and protect itself and its agents,

Each Student assigned to a rotation hereunder: (i) complies with the Rules, policies, procedures and requirements of TPMG; (ii) maintains a current acceptable physical examination report and immunization record; (iii) maintains a current TB skin test documenting a negative test for TB; (iv) provides proof of a heptavax immunization; (v) maintains a current Hepatitis B immunization record or a signed waiver, if permitted by TPMG. Tift Regional Medical Center Advanced Practice Nursing Tifton, Georgia Touro Infirmary FNP, NNP Faculty must complete Exhibit A. Student must complete Exhibit B prior to clinicals. New Orleans, Louisiana Touro Infirmary/Crescent City FNP, NNP FNP & NNP Students-Only 2 students per clinical. USA Faculty must provide agency with student name Physicians and course objectives and course outline prior to New Orleans, Louisiana clinicals. Student must have a satisfactory physical examination within the past six (6) months with medical clearance that includes; Hepatitis B titers, titers for Rubella, Rubeola, Mumps and Varicella and an TB test within the past six (6) months or bi-annual chest x-ray. If the Hepatitis B titer is negative or non-reactive, then the Learning Institution must provide proof of the Student’s vaccine that was received after the titer and provide a new titer a month after the receipt of the vaccine. The titer levels for Rubeola, Mumps, and Varicella must be greater then 1.10. If the titer levels are not greater then 1.10, the Learning Institution must provide proof of the Student’s vaccine that was received after the titer and provide a new titer a month after the receipt of the vaccine. The titer level for

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Rubella must be greater then 15. If not, the Learning Institution must provide proof of the Student’s vaccine that was received after the titer and provide a new titer a month after the receipt of the vaccine. Student must have flu shot during flu season by December 15th of each year or they will be required to wear a mask. Student must complete Exhibit B prior to clinicals. Tri County Emergency Physicians Undergraduate and Graduate Pottstown, Pennsylvania TriHealth, Inc. (covered: Good MSN, DNP and See Exhibit A for Ohio Board of Nursing Preceptor Samaritan Hospital, Bethesda Hospital, APRN Expectations. USA Faculty must obtain a copy of certificate from McCullough-Hyde memorial Hospital and student’s orientation certificate. Provide to Agency the all subsidiaries) instructional schedule 60 days prior to clinicals. Cincinnati Ohio Student onboarding-Stacey Newman ([email protected] or 513-569-6279) Orientation on-line materials are located at https://www.trihealth.com/elearning/ and then click on Student Orientation. It is mandatory for all students to complete the HIPAA eLearning. They must take the certificate of completion to TriHealth Security in order to obtain their temporary badge. It is important for all students to complete the AME Safety eLearning prior to their first clinical day. They need to print out the certificate of completion when they have completed the requirement. Measles, Mumps and Rubella - positive titer or vaccination;Tetanus/Diphtheria - within the last ten (10) years; andTuberculosis (TB) 2-step Skin Test - within the last twelve (12) months.Varicella - evidence of having had chicken pox or received varicella immunization. Seasonal flu vaccine – yearly.

Triad of Alabama, LLC d/b/a Nursing Contact: Sheila Wade | H.R. Assistant Flowers Hospital [email protected] Dothan, Alabama

No student shall be at Facility who: Has chosen to not comply with the Facility’s or Schools directives; Is unfit for duty; and/or Has not passed a test for illegal drugs and unprescribed medications within the last 12 months preceding each referral or re-referral.

Faculty shall review Addendum 1 & 2 with student prior to student clinical rotation. Student must complete and sign Addendums 4-5. Tripler Army Medical Center MSN, DNP Honolulu, Hawai’i TriStar Health System (to include BSN, MSN, DNP, USA/Faculty: Complete Exhibit C-Attestation. Please Cartersville Medical Center, Eastside Advanced Practice contact each facility for their clinical requirements and clinical placements. Medical Center, Parkridge East Hospital, Student: Complete Exhibits A&B. Parkridge Medical Center, Parkridge Valley Hospital, Parkridge West Hospital, ***Please see ALL attachments, specifically those Redmond Regional Medical Center, for Parkridge sites*** TriStar Ashland City, TriStar Centennial Medical Center Children’s Hospital at Centennial TriStar Greenview Regional

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Hospital, TriStar Hendersonville, Medical Center, TriStar Horizon Medical Center, TriStar Skyline Madison Campus, TriStar Skyline Medical Center, TriStar Southern Hills Medical Center, TriStar StoneCrest Medical Center, TriStar Summit Medical Center) Nashville, Tennessee Trover Foundation/Trover Health Students must provide copies of all immunization records to the site Clinical Education coordinator. Services (Expired-agency will renew upon student request) Madisonville, Kentucky Truman VA Hospital MSN and DNP Columbia, Missouri Tuba City Regional Health Care MSN and DNP Agency Contact: Carolee Nelson-Clinical Services Department-928-283-2588- Corporation [email protected] USA/Faculty: Provide a Tuba City, Arizona letter of good standing to facility at least 4 weeks prior to clinical start date.

Student contact for clinical is Carolee Neslon as listed above. Ms. Nelson will send onboarding packet to student via US MAIL. Contact Shari Lord, College of Nursing’s Clinical Placement Coordinator at [email protected] for any question.

Student: Must complete entry packet to include fingerprinting, available from USA Faculty, at least 90 days in advance of clinical start date. as a condition of placement at TCRHCC, each student shall provide a written statement that s/he is not currently suspended, excluded, debarred, or otherwise ineligible to participate in the Federal health care programs as defined in 42 U.S.C. §1320a-7b(f) (the “Federal health care programs”); (ii) are not convicted of a criminal offense related to the provision of health care items or services but has not yet been excluded, debarred or otherwise declared ineligible to participate in the Federal health care programs, and (iii) are not under investigation or otherwise aware of any circumstances which may result in the Educational Institution or a student being excluded from participation in the Federal health care programs, that student will immediately notify TCRHCC of any investigation, exclusion or loss of eligibility, and that student understands that exclusion from participation in Medicare or any federal health care program will result in the termination of student’s Tucson Medical Center Nurse Practitioner Faculty and Students, please see the Prevention and Program Detection of Fraud, Waste and Abuse Policy and the Tucson, Arizona Vendor Life Safety Fact Sheet.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Contact: Vicki Kelm, Student Placement Coordinator [email protected].

USA/Faculty: Provide Hospital with identification of assigned students and the desired rotational schedule for students.

Students: Must comply with Hospital’s Corporate Compliance Program. Tulsa City-County Health MSN, DNP Students: Provide documentation required by facility showing proof of any applicable vaccinations and/or Department physical examination. Provide documentation student Tulsa, Oklahoma have completed a background check and drug screening within the previous six months. Twin Cities Hospital (joint MSN, DNP USA/Faculty: Complete Exhibit C. Student: Completed Exhibits A & B. agreement with Allied Health) Niceville, Florida Twin Oaks Rehabilitation and Undergraduate Healthcare Center (Ball Healthcare and Graduate Nursing Center) Mobile, Alabama

Agency Name Programs Agency Requirements Covered UC Health (to include The Drake MSN, DNP Student must complete and sign Exhibit A -

Center and West Chester Hospital) Confidentiality Agreement. and University of Cincinnati Physcians Company, LLC Cincinnati, Ohio UCH-MHS (covers Memorial Center, EMPLOYEES ONLY Student must utilize MyClinical Exchange for Memorial North, Pikes Peak Regional, Urgent Nursing placement. Care Circle, Urgent Care Square, Urgent Care Jantill, Printers Park Medical Plaza) EMPLOYMENT STATUS Colorado Springs, Colorado Both parties agree that if a visiting USA student(s) is an employee of UCH-MHS, he or she shall: Employees ONLY Seek agreement of his or her manager before entering the clinical education program at UCH- MHS; Ensure that student/employee shall not participate in any clinical education program activities within the area(s) or department(s) in which he or she currently works; Ensure that student/employee shall not participate in any clinical education program activities during such time that student/employee is working for UCH-MHS; Reach agreement with his or her manager and the preceptor on the learning objectives of the practicum hours, the scope of practice and clinical expectations.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Umpqua Community Health Center Undergraduate and Graduate Nursing Roseburg, Oregon Students UNC Physicians Network, LLC MSN and DNP USA/Faculty: Complete Attachment B. See Attachment C for Summary of Immunization and UNC Physicians Network Group Health Requirements. Faculty will provide a list of (previously Wayne Memorial) Students and objectives Chapel Hill, North Carolina at least 14 days prior to Clinical Experience to Agency. Student background check must be completed within 6 months of the clinical experience and USA must notify Agency within 10 days prior to the beginning of clinical experience of any criminal record. Students must have substance testing within a 12- month period prior to clinical experience. All students whether an employee of the Agency or not, will be tested for controlled substances and alcohol prior to performing duties for Agency. Agency requires a 12- panel Urine Drug Screen report test from a National Institute of Drug Abuse (NIDA) approved lab on file prior to clinical experience. Only positive reports require notice to the Agency. Students- Complete Attachment D and the Confidentiality Agreement. Must obtain and maintain health insurance during clinical experience. Must participate in any orientation/training required by Agency. UNC Rex Healthcare Nursing USA/Faculty: At least 14 (fourteen) days prior to the commencement of any Clinical Experience, provide Raleigh, North Carolina Agency with a certification, signed by USA, that identifies all Students who will be placed at the Training Facility and confirms all Students have met all requirements of Agency (Appendix C). Students: Must meet all current immunization and health requirements in Appendix A. Maintain current health insurance coverage. Must sign Appendix B (Confidentiality Statement). Criminal background checks (the “CBC”). At a minimum, the CBC shall be conducted in all states where student has lived, worked or gone to school, either within the past seven (7) years, or from the date that the assigned individual turned eighteen (18) years of age, whichever is shorter. The CBC may be no more than four (4) years old at the start of the Clinical Experience.

Have a urine drug screen equivalent to the screen which as of March 1, 2017 is a seven-panel drug screen that includes amphetamines, benzodiazepines, marijuana, PCP, barbiturates, cocaine, and opiates. The drug screen may be no more than twelve (12) months old at the beginning of any Clinical Experience.

Union Hospital, Inc. MSN, DNP Acute-Care Medical Surgical Facility Terre Haute, Indiana Faculty: Complete the Certform as directed (available in the attachments file). Submit documentation of completion to USA Clinical Affairs Department.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Student: Complete Exhibits A & B. Must pass a physical exam prior to clinical at least once a year. Must obtain National Criminal Background Check to include: SS Number verification Limited Criminal History (7 years or up to 5 criminal searches) Violent Sexual Offender and Predator Registry Search Fingerprinting for those students and on-site faculty who will be assigned to the Union Hospital Child Care Center. HHA/OIG List of Excluded Individuals GSA List of Parties Excluded from Federal Programs US Treasury, Office of Foreign Assets Control Must complete mandatory orientation at facility. If bloodborne pathogen exposure occurs to student they will be treated at the Health Office form 7am-4pm. After 4pm, student is to notify Administrative House Supervisor immediately.

UnityPoint Health-St. Luke’s Graduate Nursing Sioux City, Iowa University Health Conway (BRFHH) Graduate Nursing To submit annually to the appropriate Department Programs Director/Designee a letter asserting compliance with Monroe, Louisiana health requirements prior to faculty and students starting assignment. The letter must state that all faculty and students using Hospital have met the following:

Annual proof of no evidence of active tuberculosis, demonstrated by PPD within twelve (12) months if negative, chest x-ray within one (1) year if PPD positive. If PPD is refused, evidence of status can be demonstrated with a chest film.

Rubella (German Measles)--titers required or proof of immunization.

Rubeola (Red Measles)-titers required or proof of immunization.

Hepatitis B-hepatitis B vaccine received or signed declination in file.

Please note that if there is exposure or potential exposure to rubeola or varicella, an instructor or student of USA who is serum-negative or whose status is unknown may be restricted from working in certain areas, including newborn nursery, and/or with immune-compromised and pregnant patients. Any known exposure to varicella and rubeola is to be reported to Hospital.

The letter must also state where the health records verifying compliance are kept and that they will be made accessible to the Hospital’s Infection Control staff as necessary.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered

To obtain a current updated drug and alcohol test and criminal background check on each student and to furnish Hospital with the source document evidencing the check before the class begins.

To require graduate nursing students to have a current and valid RN license.

To require the students to represent themselves as graduate nursing students while on duty.

Student- Must complete Exhibits A&B.

University Health Shreveport Graduate Nursing USA/Faculty: Provide Facility with a copy of the Programs program curriculum including goals, objectives and (BRFHH) expectations of students. Shreveport, Louisiana Student: Read and sign the Code of Conduct. Complete the Confidentiality Agreement. United HealthCare Services, Inc. Students must complete attachments prior to clinicals-See faculty d/b/a Evercare Georgia, Norcross, Georgia University Hospital and Clinics MSN, DNP Lafayette, Louisiana University of Alabama- Birmingham Nursing Students must contact Eileen Meyer- Hospitals (all clinics are covered by [email protected], Office of Advanced agreement) Practice Providers (APP). Students Do Birmingham, Alabama not contact individual CRNP’s and PA’s for preceptorships. Students will NOT be allowed access to a preceptor if they go around the process UAB has in place. University of Alabama College of BSN, RN-BSN, Community Health Sciences (UMC) MSN, DNP Tuscaloosa, Alabama

University of Arkansas (University of MSN, DNP Arkansas for Medical Sciences- UAMS) Little Rock, Arkansas UCSF Benioff Children’s Hospital- Graduate Students Students must have orientation through the Oakland Only Children’s Education and Development Department of Facility. Oakland, California University of California Irvine MSN and DNP Must provide to the Education Coordinator with a list Programs of the student’s names and addresses for the clinical UC Irvine experience, along with a copy of the approved Orange, California curriculum for each clinical experience. Student must have annual health exam. University of Central Arkansas Undergraduate and Graduate Nursing Conway, Arkansas

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered University of Chicago Medical BSN, RN-BSN, MSN, Faculty must provide a written description of the DNP program and objectives of the courses and the Center (includes Comer Children’s approximate number of students to be assigned at Hospital) any given time in the units. The names of the Chicago, Illinois students shall be submitted three weeks prior to the beginning of the semester. USA must provide the names and credentials of the faculty who will participate in the Program activities.

As of July, 2017, ALL students/instructors (if applicable) will need to complete a HIPAA training module in Oracle Learning Management System (LMS). Because nursing students and clinical instructors (if applicable) have actual patient contact, as well as EPIC access, they need to comply with hospital regulations regarding HIPAA. This is an annual requirement (returning students may need to complete the training if they are returning after one year)

UCM has updated our clinical rotation packet that contains information regarding both pre-licensure and post-licensure processes. Please note the following changes to initiating a clinical rotation at UCM: 1. ALL students and instructors (if applicable) will be REQUIRED to complete the HIPAA training module in the Oracle Learning Management System. He/she will be automatically enrolled into the module once the computer access form (page 37) has been processed through CBIS. 2. ALL are required to complete the computer access form (page 37), regardless of patient contact, charting, chart auditing or not, and to include each individual’s email address and END date of the rotation. 3. Instructions on how to access Oracle LMS and the online modules are on pages 38-41. 4. Communication with students/instructors (if applicable) will be via the school’s email address. 5. Forms MUST be submitted to Vanessa ([email protected]) no later than 3 weeks prior to the start of the rotation or may risk loss of clinical placement. 6. No changes in roster may be made once submitted. 7. ALL instructors (if applicable) that are NEW to the assigned unit; are to contact the unit(s) patient care manager AND clinical nurse educator to receive an orientation to the unit. 8. Instructors (if applicable) are not allowed to bring students onto the unit until the instructor orientation requirement has been met. University of Florida, College of NP Students must complete Exhibit A prior to beginning clinicals. This includes a 12 panel drug screen. Medicine Students will be responsible for purchasing Jacksonville, Florida additional insurance through the UF Self-Insurance Program at a fee of $100. per rotation (USA Faculty will have access to document. Student must complete and email to mailto:[email protected] include and email address for clinical affairs to return the signed form back to student). Payment is due prior to

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered the rotation start date and must be in the form of a check payable to UF Self Insurance Program. University Health Services, Inc. Nursing USA/Faculty: Certify that student participating in onsite clinical training will have had criminal Augusta, Georgia background checks and urine drug screens performed annually.

Student: Students: See Lauren Potocik for placement; see Medical Staffing, for signature of LON. Must have annual background check and urine drug screen. Must sign a written agreement (provided by facility) to observe all rules and policies established by Facility, to maintain confidentiality of patient information. At the option of the Facility, health examinations may be performed by the Facility, at the sole expense of the student participant.

University Health System MSN, DNP *LON DOES NOT REQUIRE AGENCY OFFICIAL SIGNATURE* San Antonio, Texas

USA/Faculty: Please see Exhibit 1 for agency requirements, forms must be submitted at least 2 weeks prior to beginning of clinical. NOTE: These forms are to be completed by faculty not students.

Student: Must have basic health insurance coverage. Must attend Health System Orientation. University Health System, Inc. RN-BSN, MSN, USA/Faculty: Complete Exhibit B-Influenza DNP Vaccination Summary. See Exhibit A for description (University of Tennessee) of clinical experience for nursing students. Knoxville, Tennessee Students-See Agency guidelines for students. University Hospitals Health System Nursing Certificate SEE ATTACHMENT 1 for complete list of Shaker Heights, Ohio or Degree covered Hospitals and contacts. Programs USA/Faculty: See Exhibit C for Requirements. Notify Agency at least 4 weeks prior to beginning of clinical experience with the number of students.

Student: See/Complete Exhibit A and Form A (Agency’s HR Department must receive Form A at least 4 weeks before student is scheduled to begin clinicals. Must maintain health insurance coverage.

University of Iowa Hospitals and RN-BSN, MSN, USA/Faculty: Submit in writing request for placement DNP at least 60 days in advance of first expected day of Clinics clinical experience. Agency Contact: Dr. Lou Ann Iowa City, Iowa Montgomery-Director, Nursing Professional Development & Advanced Practice-lou- [email protected]. Student: Must maintain health insurance coverage (for all health sciences students with clinical exposures as part of their training). Training should be no more than 3-12 hour shifts in a row without a 24 hour period of time off.

University of Kansas Hospital Nursing Programs USA/Faculty: Complete Exhibit A&E. See Authority Exhibit C&D,

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Kansas City, Kansas Provide Agency clinical units sought to be used. Provide the Agency detailed written educational goals and objectives for each clinical experience. These written documents shall be presented no less than one (1) nor more than six (6) months prior to the arrival of the student at the Agency. Provide the following: The absence of active tuberculosis disease Negative TB skin test (TST) or Interferon- gamma Release Assay (IGRA), within 12 months prior to the start of clinical rotation If TST for initial test, do a 2-step TB skin test (1-3 weeks apart) within 12 months of the start of clinical rotation, if no documentation of TST within last 12 months Negative PA & Lateral chest x-ray, if TB test is positive Immune status (vaccine or laboratory evidence) for: Measles (rubeola), mumps and rubella (Positive IgG for each or 2 doses of live MMR vaccine, on or after first birthday) Chickenpox (Positive IgG or 2 doses of live varicella (VZV) vaccine at least 28 days apart) Tetanus/diphtheria vaccination within the last 10 years, with a one-time dose of tetanus/diphtheria/pertussis vaccine as an adult Annual seasonal influenza vaccination Proof of vaccination according to current CDC guidelines and pending availability as soon ascurrent year’s vaccine is available as announced by CDC during the flu season (flu season is defined by the individual health care facility hosting clinical experience). Competent/adequate color vision, as demonstrated by an Ishihara test or comparable mechanical testing. If color vision is not adequate, must be cleared to work by hospital Employee Health. Repeat TB skin test or IGRA every 2 years Hepatitis B status, if the potential for occupational exposure to blood or body fluids is predictable during the performance of the job. Both criteria below must be met. Hepatitis B vaccine or OSHA letter that vaccine was offered and declined Hepatitis B Surface Antibody (anti-HBs) If positive, consider immune If negative, must be Hepatitis B Surface Antigen (HBsAg) negative to perform exposure-prone procedures (invasive surgical and dental procedures implicated in the transmission of Hepatitis B from infected healthcare personnel to patients)

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Infectious disease or blood or body fluid post- exposure evaluation and follow up Following a report of an exposure incident involving the Program Participant, the office of Occupational Health will obtain a confidential medical evaluation and follow-up for the Program Participant and will maintain post- exposure management records in accordance with applicable law If the Program Participant requires post- exposure evaluation at another facility, an incident report and post-exposure management records must be supplied to the office of Occupational Health

Student: Complete Exhibit B. Receive a tour of the facility. University of Kentucky Medical MSN ,DNP Students must contact Pat Imerman to set up their Center clinicals. Lexington, Kentucky 859-257-9196 or [email protected]. University of Louisville Physicians, Nursing USA/Faculty: Provide objectives and Inc. educational methods of the relevant program to agency. Louisville, Kentucky Students: Must have negative tuberculin skin test performed within fourteen (14) days immediately prior to clinical experiences, positive reactor students will be required to follow Agency’s employee health policy. Must complete Exhibits A&B. Require Participants to complete an orientation to, and require compliance with, standards of conduct, rules, regulations, policies and procedures established by Agency. In addition, University shall require Participants to complete the general orientation and training (including training on bloodborne pathogens, fire safety, confidentiality, abuse/neglect and operating room orientation (if applicable)) provided by Affiliating Agency and Participants shall satisfy all requirements and testing, if any, reasonably requested by Agency. University of Maryland Medical Nursing USA/Faculty: See Schedule B for UMMS Affiliates Specific Terms and Conditions. System Corporation (covers all of affiliates entities, including Provide UMMS Facility with the names of and University of Maryland Community pertinent information about each student assigned to UMMS. Also, provide UMMS Facility with current Medical Group) course outlines, course objectives, lists of faculty Baltimore, Maryland members and copies of evaluation forms for each student. Provide, as needed a description of specific learning experiences and required assignments. Students: Flu vaccinations will be required for students whose clinical experiences occur between October 1 and March 31. Must have health insurance that is effective during the full time of the student’s clinical experience. Must participate and successfully complete the UMMS required training,

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered including, but not limited to, universal precautions and infection control practices, safety practices, and disaster preparation. All students will attend and complete any orientation required by UMMS. University Medical Center New Nursing Clinical experience should be through the Orleans Director of Nursing Education and Professional Development at Hospital. New Orleans, Louisiana USA/Faculty: Must provide specific learning objectives for the clinical experience in advance of assignment of the student to facility. Submit annually to the appropriate Department Director a letter asserting compliance with health requirements prior to on-site faculty and students starting assignment. Letter must state that all faculty and students have met with Current TB skin test (PPD), applied within six months before patient contact and yearly thereafter. If the PPD is positive, active disease must be ruled out.

Rubella (German Measles)-immunity proven by titer or documentation of 2 injections of MMR.

Rubeola (Red Measles)- immunity proven by titer or documentation of 2 injections of MMR.

Hepatitis B-hepatitis B vaccine should be completed or in progress for health care workers at risk for occupational exposure to patient blood and other potentially infectious materials.

Varicella (Chicken Pox) titer or history of disease is required. Vaccine is recommended but not required when there is neither protective titer nor history of disease. Susceptible health care workers who refuse vaccination may not be permitted to work with immunocompromised patients and pregnant patients. They are instructed to report any known Varicella exposure to the appropriate HOSPITAL personnel. Refer to the Employee Health Varicella policy which will be provided upon written request.

Please note that if there is exposure or potential exposure to rubeola or Varicella, an instructor or student who is sero-negative may be restricted from working in certain areas and/or with immunocompromised and/or pregnant patients. Any known exposure to Varicella and rubeloa is to be reported to appropriate HOSPITAL personnel.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Current influenza vaccination or declination and a one-time tetanus diptheria-pertussis (T-dap) vaccine is recommended.

A criminal background check and a drug screening.

The letter must also state where the health records, background check, and drug screening results verifying compliance are kept and that they will be made accessible to the HOSPITAL’s Infection Control staff and Education Department staff as necessary.

To see that all newly employed and continuing faculty using the facilities of HOSPITAL will annually:

Participate in an orientation program, to include TJC/Safety Program developed and presented by the HOSPITAL.

Inform students of content presented in the TJC/Safety program.

To enforce compliance with all HOSPITAL policies and procedures.

University Medical Center of El Paso RN, NP Students must complete agency’s Non-Disclosure Agreement and the last page of Code of Conduct (formerly R.E. Thomason General Manual. Also students must attend orientation Hospital) provided by the hospital prior to beginning clinicals. El Paso, Texas Students must comply with the agency’s regulations regarding Electronic Media (if applicable, please see Addendum E). Student may need to supply the agency with a background check that includes personal references and their credit history if applicable. University Medical Center of Nursing Students and On-Site Faculty must attend a hospital orientation (set up by facility), and complete exhibits Southern Nevada A&B (if applicable) provided by facility. Las Vegas, Nevada USA/Faculty: At least one month prior to the beginning of clinicals, the start date and length of the experience will be mutually agreed upon by the parties, as well as the number of students eligible to participate. Factors to be considered by the parties in determining start dates, program length and student numbers shall include: (i) the number of staff members available to train students; (ii) the work load of staff members; and (iii) maximum student saturation by clinical unit/department. SCHOOL and HOSPITAL will designate and submit in writing to the other the name of the person to be responsible for coordination of the Program on its behalf. Those persons will be called “Program Coordinators.” SCHOOL and HOSPITAL will notify the other in writing of any change or proposed change of their

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered respective Program Coordinator. A minimum of one week prior to arrival at HOSPITAL, SCHOOL will provide to HOSPITAL a roster of student’s names and dates of planned clinical experiences and/or a roster of instructors (if applicable) who will be onsite at HOSPITAL premises.

Students: Must complete Exhibit A-provided by facility. Must be covered by health insurance. Have completed a pre-placement drug screen and two- step TB testing; (iii) obtained proof of exposure to or vaccination against Rubella, Rubeola and Varicella; and offered the individual the option of receiving Hepatitis B vaccine. All background checks must be completed by HOSPITAL’s designated provider and accepted by the HOSPITAL a minimum of one (1) week prior to the student’s and/or instructor’s arrival at HOSPITAL. University of Michigan Health MSN, DNP Student must carry health insurance. System Ann Arbor, Michigan University of Minnesota Physicians MSN, DNP Minneapolis, Minnesota

University of Mississippi Medical BSN, RN-BSN, MSN, NOTE: This is Faculty driven, not Clinical Affairs. DNP Students must contact USA Faculty 8 weeks prior to Center and all of UMMC’s Clinics clinical experience. (Jackson Area) https://www.umc.edu/Office%20of%20Academic%20 Jackson, Mississippi Affairs/For- Students/Academic%20Affiliations/Affiliated%20Stud ents%20at%20UMMC.html

*AGENCY REQUIRES THIS 8 WEEKS PRIOR TO CLINICALS.

Scheduling Badging/Criminal History Review for Affiliated Students at UMMC

At least 4 weeks before the start of rotations at the UMMC Jackson or Grenada campuses, the affiliated program coordinator should utilize the link below to schedule badging/criminal history review appointments for their students. The affiliated program coordinator may choose to schedule the appointment on the students' behalf or forward the link below to the students so that they may self- schedule.

If students already have notarized and unexpired “clearance letters” issued by a licensed healthcare facility in Mississippi, please select the “Affiliated Student Badging ONLY” appointment type and attach copies to the appointments for review. If students do not have valid clearance letters, please

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered select the “Affiliated Student Badging and Fingerprinting” appointment type.

IMPORTANT: For larger groups of 10 or more students, affiliated program coordinators should account for additional processing time and make arrangements to pick up students' completed badges in a batch. If students are self-scheduling, instruct students to answer “My instructor will pick up the badges as a group” when they schedule their appointments.

For rotations with the UMMC campus in Holmes County, MS, please contact Kimberly Sellars at [email protected] or 662-227-7011.

For general questions, please contact the UMMC HR Service Center at [email protected]

Link to Schedule Appointments for Badging/Criminal History Review: https://hrumc.acuityscheduling.com/schedule.php?a ppointmentType=category:Affiliated+Student+Badgin g Please note: The affiliated student spreadsheet MUST be submitted at least 4 weeks prior to the start of the rotation. Complete only the blue portion of the affiliated student spreadsheet; the green portion of the spreadsheet is for UMMC use only. Be sure that each student/instructor’s information is complete before submitting the form (the full SSN must be included).Be sure that all student/instructor’s meet the requirements found in the Affiliated Student On- Boarding Checklist. The UMMC Affiliated Student Coordinator for your area can be found at the following link, please feel free to contact them with your questions/concerns.

Nursing Instructors Adrienne S. Murray [email protected] Nurse Practitioner Derek Holt [email protected]

Students must complete Epic System Training. Visit affiliated student webpage www.umc.edu, click on Education tab, then affiliated students under Resources.

University of Missouri Health Care MSN, DNP USA/Faculty: Complete Attachments 1 & 2 and Columbia, Missouri return to facility (fax number listed on attachment) prior to beginning of student’s clinicals. Student: Complete Attachment 3- Confidentiality Agreement. Upon Facility’s request provide evidence of Hepatitis B vaccine or a signed statement declining Hepatitis B vaccine.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered University of New Mexico Hospitals MSN, DNP USA/FACULTY: PLEASE SEE ALL ATTACHMENTS FOR THIS AGREEMENT. THERE (also covers Young Children’s ARE SPECIFIC BACKGROUND AND Health Center) FINGERPRINT INSTRUCTIONS. PLEASE READ Albuquerque, New Mexico THE INFORMATION SHEET FIRST.

Agency requires student(s) be complete drug screening within 6 months before beginning clinicals at UNMH. Faculty to complete Exhibit A. Student(s) must provide UNMH and USA CON with copy of certificate of insurance as proof of their property damage coverage. USA/Faculty: Must complete the Request for Placement form. Student must submit an application for a Criminal History Screening to the NM DOH (New Mexico Dept. of Health) in accordance with the NM Caregivers Criminal history Screening Act. Must complete the CYFD Clearance Application. NM CYFD Contact. Mary Gutierrez 505-827-9952 [email protected] University of North Carolina BSN, RN-BSN, MSN, Agreement only covers preceptors employed by the DNP Hospital. If preceptor is employed by the School of Hospitals (UNC Hospital, Medicine, we will need a different contract. Hillsborough Hospital and Wakebrook) Faculty must provide number of student(s), course objectives, and responsible faculty member from Chapel Hill, North Carolina USA to UNC’s program coordinator. Faculty and Student please read Appendix A. prior to beginning clinicals. Students must maintain health insurance coverage. Sign the current Agency Confidentiality Statement (available from Agency). Students Have been the subject of a criminal background check (the “CBC”). At a minimum, the CBC shall be conducted in all states where the Program Participant has lived, worked or gone to school, either within the past seven (7) years, or from the date that the assigned individual turned eighteen (18) years of age, whichever is shorter. It is the responsibility of the Educational Institution to review all CBCs. The CBC may be no more than four (4) years old at the start of the Educational Experience. Have undergone a urine drug screen equivalent to the screen that the Training Facility requires, which as of March 1, 2017 is a five-panel urine drug screen that includes the following: cocaine, opiates, amphetamine,/methamphetamine, PCP, and THC. In the event the Training Facility changes its standard urine drug screen requirements to an eight-panel or twelve- panel screen, the Training Facility will provide three months written notice of such changes to the Educational Institution and this Agreement will automatically be amended to include the then- current Training Facility requirements. It is the responsibility of the Educational Institution to review all drug screens. The drug screen may be no more than twelve (12) months old at the beginning of any Educational Experience. University of North Carolina - USA/Faculty - submit a schedule and list of students at least fourteen days prior to clinicals. Submit Chapel Hill School of Nursing Appendices A-E, current clinical objectives, system Chapel Hill, North Carolina for reporting student performance and attendance, evaluation forms. Must provide exposure control plan

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered and guidelines in accordance with OSHA Standards for Blood borne Pathogens and TB. USA will provide a copy of its exposure control plan and guidelines to facility upon request. Must notify facility of within ten days prior to clinical if student has criminal record.

Student - must obtain and maintain health insurance. Must participate in any orientation/training required and provided by facility. Criminal background check must be completed within six calendar months from the date the student begins clinicals.

University of North Florida Nurse Educator (Brooks College of Health) Jacksonville, Florida UPMC University of Pittsburgh UPMC EMPLOYEES UPMC EMPLOYEES ONLY ONLY Student must complete Exhibit A. Pittsburgh, Pennsylvania Graduate Nursing UPMC EMPLOYEES ONLY Programs Provide name of each student prior to that student’s clinical experience. No student or faculty member will be permitted to begin participation in any clinical or educational experience at a UPMC facility until he or she has provided UPMC with written verification he or she has had a health examination, tuberculin screening, hepatitis B immunizations, rubella titer and history of varicella. If the individual’s varicella history is questionable a varicella titer must be obtained and the results of the tuberculin screening must not be more than one year old. Each student that he or she must apply for and receive Pennsylvania Act 33/34 clearance and a fingerprint criminal history check through the Federal Bureau of Investigation pursuant to Pennsylvania Act 73 prior to that student’s first day at UPMC, each Program shall advise each student who will be placed at UPMC that he or she is required to submit the documents evidencing such clearances to the UPMC representative coordinating the student’s activities under this Agreement no later than the first day of the student’s participation in program activities on UPMC premises. In the event a student is not a Pennsylvania resident or the UPMC facility where the student experience takes place is not located in Pennsylvania, different or additional clearances may be required in accordance to UPMC policy. The clearances described in this section will be considered acceptable provided they were issued by the appropriate agency no more than five years before the student submits them. Failure to produce such documentation will result in the immediate termination of student from participation in UPMC’s clinical rotations and educational experiences. UPMC reserves the right to prohibit a student from participation in clinical rotations and educational experiences at UPMC facilities if information contained in the criminal records submitted by the student causes reasonable concern about the student’s competency or trustworthiness. Students may be required to provide evidence of lawful status in the United States.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered See Agreement for any On-site Faculty requirements. University of South Alabama Pre-Nursing Students Students must complete Exhibit A. Only Medical Center and University of South Alabama Children and Women USA Health-University of South BSN, RN-BSN, Alabama Hospitals (to include the MSN, DNP USA Student Health Center, and USA Children’s and Women’s, All USA Facilities are covered by USA Health) Mobile, Alabama

University of South Carolina, Undergraduate and College of Nursing Graduate Students Columbia, South Carolina University of Texas Health Science Pediatrics Department of Pediatrics and Department of Department of Pediatric Surgery Only-Must complete a program Center at Houston (UT Health) Pediatric Surgery agreement for additional programs. Houston, Texas USA/Faculty: Prior to the beginning of clinical provide facility with names of the student, level of academic preparation, length and dates of clinical to Anthony Garcia-Dept of Pediatrics University of Texas MD Anderson MSN, DNP USA must (if applicable) ensure that each Student has secured and maintains all documentation Cancer Center required for Student to enter and stay in the US. Houston, Texas University of Texas Southwestern MSN, DNP USA/Faculty: Complete Student Spreadsheet and Complete Agency’s Attestation (available in (also covers William P. Clements Jr. Sakai).Provide the names and schedules of the University Hospital) student participating in the clinical experience. Dallas, Texas Provide verification upon request that each student has complied with the following screening under facility's policy (10 panel urine drug screen, lab tests ***Parkland Memorial Hospital may for (mumps, rubella, varicella, rubeola, and hepatitis require separate agreement check with B titers with positive titers), and immunizations including influenza and OSHA requirements. facility.*** Student: Complete the below online training modules, information for these modules will be provided by facility's coordinator. Information Security and Health Insurance Portability and Accountability Act. Background check must include the last seven years of employment.

University of Utah Hospitals and MSN, DNP Student will be responsible for health Clinics insurance.

Salt Lake City, Utah Faculty: At least four weeks prior to the beginning date the agency must be sent the name of each student, student info (immunizations, background check, etc.) and the program description to the University of Utah Hospitals and Clinics. Provide HIPAA training. Facility contact: Milton Burbidge- or Eddie Decker 801-213-3491.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered University of Virginia Medical Center Nursing and Nurse USA/Faculty: Provide to Agency roster of names of Practitioner Programs the students, along with a rotation schedule to and Transitional Care Hospital agency sixty (60) days before clinical begins. Also, Charlottesville, Virginia provide Agency with clinical learning objectives, schedules and assignments.

Agency Contact:Leah Wayner - [email protected] University of Washington Medical Graduate Nursing USA/Faculty: Agency will need a Letter Agreement Programs to include the following: Center Beginning dates and length of experience (to be Seattle, Washington mutually agreed upon at least one month before the beginning of the clinical education program); Number of students eligible to participate in the clinical education program; Specific days, hours and locations for the clinical education program; Specific learning objectives and performance expectations for students; Specific allocation of responsibilities for the faculty Liaison, clinical education Supervisor, and Preceptors, if any, identified elsewhere in this Agreement; Deadlines and format for student progress reports and evaluation forms.

Students: Prior to the start of the education program, Student must have the following: Measles: TWO vaccines or a positive antibody titer. The doses must have been received after 12 months of age and at least one month apart. They must be given after 1/1/68 and not given with immune globulin. Persons born before 1/1/57 must have proof of one dose or a positive antibody titer. Tuberculosis Screening: In addition to a current PPD skin test within 2 months of the start of the education program, another PPD is required within the last year; otherwise a 2-step PPD must be done. History of BCG is not a contraindication to PPD testing. If student has had a positive TB skin test in the past, School must submit records specifying the test, chest X-ray report and details of prescribed medication. An annual "symptom review" is required for students with a history of positive skin test Mumps: One immunization, a positive antibody titer, or documented history of the disease. Rubella: Proof of one immunization or a positive antibody titer. History of the disease is not acceptable. Hepatitis B: Immunization is required for all students who have contact with patients or with human blood, tissue and/or body fluids. Tetanus-Diphtheria: a basic childhood series and a booster within the last ten years. Varicella (Chicken Pox): History of the disease is acceptable. Otherwise, a positive antibody titer or proof of two doses of vaccine, at least one month apart. Student must have background check, which includes the national criminal information, and a “Child and Adult Abuse Law” criminal background check pursuant to RCW 43.43.830-.842. Students, provide Agency with a copy of the check results School acknowledges that placement of each

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered student at the Agency is contingent upon provision of check information to the Agency dated less than two years prior to the start of the education program. Student should have comprehensive health and accident insurance. University of Wisconsin Hospitals Graduate Nursing USA Clinical Affairs-Program Memorandum must be renewed yearly. See Audit information if and Clinics Authority and its applicable. affiliates including the University of See updated Exhibits A-C-2018 Wisconsin Medical Foundation, Inc. USA/Faculty: Complete the Student Student Placement Certification (Exhibit A). See Madison, Wisconsin Instructions for Enrolling in Computer System. Authorization by Student. Before a student begins any direct patient contact in UWHC facilities or programs, School agrees to obtain from the student a written authorization permitting release to UWHC of the information required by this Agreement. School agrees to use an authorization form that complies with HIPAA, FERPA, or any other applicable state or federal law. Where to Send Information. The copies, letters and other information that School is required to provide under this Agreement shall be submitted to University of Wisconsin Hospital & Clinics – Education and Development for Nursing and Patient Care Services H6/227, 600 Highland Ave. Madison WI, 53792-9305, unless UWHC provides School with written notice that of another recipient. Student: Must complete Confidentiality Agreement. Must have a “Caregivers Background Check”, form is available through the Wisconsin Department of Health and Family Services website at https://www.dhs.wisconsin.gov/caregiver/index.h tm If the form ceases to be available at this website, School shall contact Facility to provide the new website or a copy of the form. Other Training requirements. School agrees that students sent to UWHC for clinical training will have a certificate on file at the School of satisfactory completion of the UWHC online safety and infection control training program. The test can be accessed as follows:

1. Go to: https://www.uwhealth.org/moodle/ 2. Select Safety and Infection Control 3. Select Safety and Infection Control, Non- Employee, Students 5. Read materials and take the test

Upon passing the test, the printed certificate must be provided to School's Clinical Affairs Office to keep on file. The School will make records available to UWHC upon request. If there are problems accessing the online training program, the Director of the Academy at UWHC (608- 261-1722) can be contacted for assistance. UWHC may change this access procedure or contact by providing written notice to Schools with Program Memoranda in effect.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered UPMC-Pinnacle Health (Pinnacle Health MSN, DNP USA Faculty and Students please see the Hospitals, Pinnacle Health Medical Services, updated Student System Requirements and Pinnacle Health Cardiovascular Institute, Pinnacle Criminal Offenses List. Hepatitis B vaccine is Health Medical Group) required by the facility for ALL students and on- site faculty. Harrisburg, Pennsylvania USA/Faculty: Submit names of the students and related documents to facility at least 4 weeks prior to clinicals.

Students: See Student website: http://www.pinnaclehealth.org/Job- Opportunities/Student-Career-Information.aspx Encouraged to obtain hospital health insurance coverage. Provide proof that student has had no conviction of any crimes listed in the Pinnacle Health Criminal Background check and Offense Policy. Must complete facility's online education regarding blood borne pathogens, standard precautions, the process of reporting exposures, information of hazardous substances, and importance of having exposures evaluated and treated. Must complete Pinnacle Health's online education regarding the application of Pennsylvania's Medical Care and Reduction Act to hospitals. US Acute Care Solutions (MEP Undergraduate and Graduate Students Health LLC) Canton, Ohio US Army Medical Department MSN, DNP USA/Faculty: Submit at least 30 days in advance of clinical the names of students, dates and hours of Activity-Alaska each training period and the clinical activities in Ft. Wainwright, Alaska which training is being requested. Agency contact: JERREMIE V.L. SIEGFRIED, MSN, RNC-OB| LTC, AN | Chief, Hospital Education, MEDDAC-AK [email protected] US Naval Hospital MSN, DNP Student must sign Trainee Agreement Okinawa, Japan Addendum

Agency Name Programs Agency Requirements Covered Valley Behavioral Health Nursing Salt Lake City, Utah Valley Care Clinics and Heart RN-BSN, MSN, Clinics DNP Edinburg, Texas Valley Health System, LLC (to include: MSN, DNP USA Faculty must notify hospital of planned clinical Centennial Hills Hospital, Spring Valley training experience, area, date of arrival, name of student. Provide a copy of the performance Hospital Medical Center, Valley Health objectives for the Training Experience. Consult with Center, Desert Springs Hospital & Valley Hospital’s Rep. for the student evaluation process.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Hospital Medical Center, Summerlin Hospital Student must have training in blood and bodily fluid Medical Center, LLC, Henderson Hospital standard precautions consistent with the US Centers and Desert View Hospital) for Disease Control and Prevention Guidelines and provide certificate to hospital. Student must have Las Vegas, Nevada background check to include statewide criminal search, civil and criminal public filings for the State of Nevada. Student must submit the background check via PRE-CHECK to the hospital prior to beginning clinicals. Student must sign Exhibit A and B. Student must provide certificate of flu vaccination each year they are in clinicals. Valley Health System Nursing USA/Faculty: Complete Exhibit F-Validation of Readiness. Notify Facility at such time as the student Winchester, Virginia is no longer enrolled at USA Program, or is no longer in good standing at USA.

Student: Must maintain professional liability insurance in the current amounts required for the state of Virginia (See Exhibit E). Student must complete Exhibits A-D. Student must have health insurance adequate to cover any illnesses or injuries sustained from going to, working at or coming from Healthcare Facility. Vanderbilt University Medical Center MSN, DNP USA/Faculty: Must request student placement (Hospital, Clinic, Children’s Hospital) at agency in writing (to include: type of unit, number of students, names of students, Nashville, Tennessee desired dates and time of placement, including days of week and hours to be on units) at least 90 days prior to the start of rotation. Please note: this agreement does not cover West End Women's Health, which is Students: See Exhibits A-C Two Step TB Vanderbilt School of Nursing Clinic. within 3 months of clinical-see Exhibit C. Note: Background requirements on Exhibit B-one year. See agency contact specialist regarding special instructions/attachments required before clinicals. Students must obtain health insurance coverage. Variety Children’s Hospital, Inc. BSN, RN-BSN, MSN, Students must register and complete all of the DNP required information at: d/b/a Nicklaus Children’s Hospital http://www.mch.com/page/EN/44/For- Miami, Florida Medical-Professionals/For-Students.aspx. Renewal in process-set to expire Students are required to submit their paperwork on line ten (10) days prior to the beginning of clinicals. on 9/30/2018 All information can be sent to Aida Panciera ([email protected]). USA must provide MCH with a signed Attestation of Student Screening for each student, not less than ten (10) days prior to the beginning of clinicals. USA and Student must meet the requirements in the MCH student orientation package. Available at http://www.mch.com/page/EN/5162/For- Students/Student-Orientation-Packages- .aspx. This will include the student obtaining Level 2 fingerprinting, if applicable. Vaughan Regional Medical Center Selma, Alabama VA Medical Center (W.G. (Bill) Students must contact Valeria Smith for any clinical rotation request. Hefner) [email protected] Salisbury, North Carolina

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Faculty must complete the Clinical Education, Clinical Instructor, and Request for use of Clinical Facilities forms. prior to the student beginning clinicals and the 2016 Checklist. VA Healthcare System Central BSN, MSN, DNP Alabama Montgomery and Tuskegee, AL VA Central Iowa Health Care CNL CNL students only System Knoxville and Des Moines Divisions Veterans Affairs Gulf Coast BSN, MSN, and Nursing: BSN, MSN, DNP. DNP Agency requires Trainee Qualifications and Healthcare System (Covers, Eglin, Credentials Verification Letter (TQCVL) signed by Pensacola, Panama City, Mobile Program Director. and Biloxi VA’s) Students must go to the VA Gulf Coast in Biloxi Biloxi, Mississippi to “Process In” this includes fingerprinting 7-120 days prior to rotation, once that is complete must return there to be issued their Badge. Students must send copy of completed paperwork to Sonya Ramsey - [email protected]. Please see the 2016 “Mandatory Training for VA Health Professions Trainees)

Faculty: Agency may request a Clinical Instructor Profile form filled out. USA FACULTY- Please read the Trainee Process and make sure students are aware of each step. VA Healthcare Center of Bay Pines BSN, MSN, DNP USA/Faculty: Letter of Agreement required for each program, to be submitted by the Clinical Affairs Bay Pines, Florida Office prior to students clinical.

BSN, MSN, DNP USA Faculty: Complete TQCVL form. Student must contact agency to be fingerprinted 1 month prior to rotation. Student cannot begin until results are back. VA Hospital Denver MSN-FNP MSN-FNP ONLY USA/Faculty: Please complete Attestation and Denver, Colorado TQCVL documents. VA Medical Center Kansas City BSN, MSN, DNP Kansas City, Missouri VA Loma Linda Healthcare System MSN Programs Loma Linda, California VA Long Beach Healthcare System MSN, DNP January 2017-Please note the following 4 Long Beach, California updated required documents. N-WOC TQCVL Letter Non-Citizen TQCVL N-SF 61

Agency Contact: Jason Lytle- [email protected] See website for updated documents: http://www.longbeach.va.gov/careers/ Nursing.asp

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered

REQUIRED FORMS:

1. Clinical Rotation Communication Checklist (MUST BE COMPLETED BY THE INSTRUCTOR PRIOR TO TURN IN OF STUDENT FORMS BELOW) 2. Trainee Qualifications and Credentials Verification Letter (TQCVL) 2. Application Form (VA Form 10- 2850D) 3. WOC Appointment Request Letter 4. AIS Form (Make sure this form is completely typed. Also, ensure you fill in the Start Date and Termination Date (End Date)). 5. VHA Mandatory Training (Certificates of Training)(See the attached Self Enroll Health Trainee Instructions) 6. PIV Form

I have attached the required forms to this email. Forms must be submitted at least 6 weeks prior to the anticipated rotation start date. Once all the forms are correctly filled out and signed, scan the forms in the order listed above individually by student to a PDF file. Email me each scanned student .pdf file (Example: williams.pdf) or you may mail or hand carry the completed forms. I will contact you via email once all of the students have been processed through Nursing Education and are ready for in- processing through HR.

Instructions for VA Long Beach Fingerprinting(HR, building 165, walk-in hours 8:30am - 4:00pm): - US Citizens ensure you bring two (2) forms of valid, unexpired, government identification. - NON-Citizens: One (1) form of Identification must be your green card, resident alien card, or VISA. - NATURALIZED Citizens: One (1) form of identification must be a US Passport or the letter with your picture stating you are a US Citizen.

PLEASE NOTE: At the end of the rotation the Learner's Perception Survey memorandum needs to be completed/signed by the student and emailed back to me. The

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Learner's Perception Survey (LPS) is a mandatory requirement for all nursing students rotating through the VA Long Beach Healthcare System for clinical assignment. Link for the Learner's Perception Survey: http://www.va.gov/oaa/surveys/ VA Maryland Health Care System Baltimore, Maryland VA Medical Center of Alexandria, LA GAPNP, BSN, Gerontological/Adult Psychiatric NP (On-Line) Bachelor and Master Alexandria, Louisiana MSN VA Medical Center of Ann Arbor MSN Nursing Program, Master’s

Ann Arbor, Michigan VA Medical Center of Asheville, NC Advanced Practive Advanced Practice Nursing Asheville, North Carolina VA Medical Center of Atlanta MSN, Geron. NP, Atlanta, Georgia RN-BSN, MSN, DNP VA Medical Center Birmingham BSN-MSN and Birmingham, Alabama DNP VA Medical Center of Carl Vinson MSN, NP NP: Masters Program Dublin, Georgia VA Medical Center of Charlie MSN-GNP, DNP Nursing (MSN-GNP Degree Programs) DNP Students Norwood Augusta, Georgia VA Medical Center of Cheyenne BSN, RN-BSN, Nursing/Nurse Practitioner/MS Cheyenne, WY MSN, DNP VA Medical Center of Cincinnati BSN, MSN, DNP BSN and Graduate Nursing Students Ohio Cincinnati, Ohio VA El Paso Health Care System MSN and DNP El Paso, Texas Programs VA Medical Center Fayetteville Advanced Practice Nurse Practitioner DNP Fayetteville, Arkansas VA Medical Center of Grand MSN MSN students Junction Grand Junction, Colorado VA Medical Center of Huntington Huntington, West Virginia VA Medical Center - G.V. (Sonny) BSN, Montgomery Adult Geron Acute, Adult Geron Jackson, Mississippi Primary (including Palliative Care), Psych NP, Post Masters, MSN and DNP VA Medical Center Lexington Adult Geron Primary

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Lexington, Kentucky NP-MSN ONLY VA Medical Center Louis Stokes BSN, MSN, DNP Cleveland Cleveland, Ohio VA Medical Center of Marion, IL MSN Starting with the Fall 2018 semester, any student that is hosted by our facility will have to have a Marion, Illinois completed Trainee Qualification and Credentials Verification Letter (TQCVL). This letter is initiated by the educational institution and sent to the Education Tech and Christine Stearns at [email protected] no later than 60 days before the clinical rotation that the student/s will complete. See updated requirements attachment.

Call 618-997-5311 ext. 54013 to schedule fingerprinting appointment Attached is the paperwork that needs to be completed prior to starting your rotation at the Marion VAMC. As soon as it is complete, you will need to contact Human Resources to set-up an appointment to get fingerprinted and to turn in your paperwork. Please remember you must be fingerprinted at least 1 month before your rotation begins. Please print and complete all attachments and call 618-997-5311 ext. 54013, Kim Turk, to schedule a fingerprint appointment & to turn in your paperwork. Bring completed forms with you the day of your appointment. If you have specific questions related to the forms please contact Tammy Cesar-Sargent (contact information below). Human Resources is your contact for scheduling fingerprinting appointments and questions regarding the paperwork

Attached are instructions, on how to log on to the Talent Management System (TMS) website to complete the mandatory education module. You are only required to complete the Mandatory Training for Trainees. If any other items show up on your “To-Do List” please ignore them. Please print out a completion certificate for your records and give to your preceptor-you do not have to turn in a certificate to me. Any questions related to the education modules, please contact Christine Stearns (contact information below).

I have also attached an instruction page regarding our Learner’s Perception survey. Please log onto the website on your last day and complete the survey – it only takes 10 minutes. This is the only feedback we receive about your rotation!

If you are here less than 15 days you can use your student ID badge as your ID badge while at the facility. If you are here for longer you will need to receive a VA issued ID badge.

Lastly, we need verification that you have received a TB test within the last year and received a negative result. Please turn in this information with the rest of your paperwork. Please keep in mind that you must

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered be fingerprinted at least 1 month prior to your first clinical rotation day, no exceptions. Your preceptor will be notified when your fingerprints have cleared and you are eligible to start your internship/rotation

All of this information is also available on the Marion VAMC homepage. VA Medical Center of Memphis, TN Memphis, Tennessee VA Medical Center of Michael DeBakey Center Houston, Texas

VA Medical Center of New Mexico BSN, MSN BSN and MSN Albuquerque, New Mexico

VA Medical Center of Graduate Graduate Degree Northhampton, MA Leeds, Massachusetts VA Medical Center of Overton BSN, RN-BSN, Undergraduate & Graduate degrees in Science of MSN, DNP Nursing Brooks TQCVL Paperwork in agency attachment folder. Shreveport, Louisiana Graduate Degree. USA Faculty please ask Dr. Rhodes to sign the TQCVL form. VA Medical Center of Portland, OR MSN and DNP All students at VAPORHCS be aware of the policy that they must have the seasonal influenza Portland, Oregon vaccine or wear a mask throughout the influenza season (Dec 1-March 31). To access forms from the VA application website to ensure you and your students receive the most current application information and documentation: http://www.portland.va.gov/Education/AlliedHealthSt udent.asp

VA Medical Center of St. Louis, MO St. Louis, Missouri VA Medical Center of Tuscaloosa, BSN, MSN, DNP Alabama Tuscaloosa, Alabama VA Medical Center (Wm. Jennings MSN-Family Psych Faculty-Educational Institution Verification Letter Only must be signed and sent from USA CON, Associate Dorn) Dean for Academic Affairs to: Columbia, South Carolina Wm. Jennings Dorn VA Hospital Attn: Tom Wiseman Administrative Officer-Education (141) 6439 Garners Ferry Road Columbia, SC 29209 VA New Jersey Healthcare System MSN and DNP Lyons, New Jersey VA North Texas Medical Center AGPNP, RN-BSN- Starting with the 2017-18 flu season the flu MSN, MSN, vaccination will be a required vaccine. Dallas, Texas USA/Faculty: TQCVL must be completed for each student. Advanced Geropsych Assessment Older Adults Practicum RN-BSN-MSN

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Master of Science in Nursing [email protected] 214-857-0768. Student’s need about 6-8 weeks to “clear” before coming to the VA. VA fingerprint and process with H R. It will take at least 30 days from fingerprinting to “clear”. VA North Florida/South Georgia RN-BSN/BSN, RN-BSN/BSN & MSN Please see attachments from MSN agency. Faculty and Students please allow 6-8 Health System weeks for processing time. Gainesville, Florida

VA Northern California Health Care BSN, MSN, DNP System Mather, California VA Northport Medical Center BSN, MSN, NP Nursing Baccalaureate Degree, Northport, New York Masters Degree NP VA Oklahoma City Medical Center Nursing Contact USA Clinical Affairs for Clinical Request Oklahoma City, Oklahoma Timeline -see below.

NURSE PRACTITIONER/GRADATE STUDENT TIMELINE FOR CLINICAL REQUESTS OKC VAHCS – NURSING SERVICE

Graduate students should submit their requests for a preceptor within the dates indicated for the entry point they are seeking clinical hours. No clinical requests will be accepted before or after the posted dates for the entry point identified. Please note the fingerprinting deadline may be subject to change based on HR requirements/etc. New dates will be posted as soon as possible following any process change.

Availability of preceptors is determined by date/time of clinical request and the type of clinical rotation/needs. The number of preceptors available per entry point may vary so slots are not guaranteed even if a request is submitted early. Please note that hours during the summer entry point may be limited due to preceptor schedule, etc.

Clinical documentation requirements (e.g. immunizations, CPR) must be current through the semester/clinical rotation. Exceptions to this requirement include the student’s nursing license and certificate of insurability; however, these items MUST be updated/received before expiration. If documentation is not received prior to expiring, the student will not be able to return for clinical. There will be no exceptions for expired documentation.

Advanced Practice Student(s) will be responsible to the Chief Nursing Service, Patient Care Service through the Associate Director, Nursing Service, and Nurse Manage for selection of case load and direct supervision of students assigned to units for clinical experience. Provide the following to the Chief, Nursing Service at least 3 weeks prior to clinical experience;

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Names of students including middle initial, birth date, addresses, telephone numbers, and social security numbers. Statement of good health for each student. Evidence of completion of CPR certification, Health Care Provider level, Certificates of completion of MTT and Glucometer training. Make available to the Chief, Nursing Service written materials on the course, learning objectives for the clinical experience, policies, and related information including responsibilities of instructors.

VA Outpatient Clinic Graduate, MSN Graduate Program, Master of Science in Nursing Chattanooga, Tennessee VA Pacific Islands Health Care MSN MSN students only System Honolulu, Hawai’i VA Phoenix Healthcare System Phoenix, Arizona VA Puget Sound Health Care System Seattle, Washington VA Roseburg Healthcare System USA Faculty, please complete the Education Program Letter of Agreement for each student and Roseburg, Oregon return to: Amanda [email protected] 541-440-1000 x 44225. VA Sierra Nevada Health Care System Reno, Nevada VA Southeast Louisiana Health MSN and DNP Student must have the TQCVL form completed through Clinical Affairs Care (New Orleans VA) New Orleans, Louisiana VA Southern Nevada Healthcare MSN and DNP System North Las Vegas, Nevada Ventura County Behavioral Health MSN, DNP Oxnard, California Victory Health Partners Undergraduate and Mobile, Alabama Graduate Nursing Vidant Health (to include: Vidant MC, Vidant RN-BSN, MSN and Facility Education Contact: Cathy Bellamy Beaufort Hospital, Vidant Bertie Hospital, Vidant DNP [email protected]. Chowan Hospital, Vidant Duplin Hospital, Vidant Edgecombe Hospital, SurgiCenter of Eastern USA/Faculty: Coordinate with Hospital and ensure Carolina, Outer Banks Hospital, Vidant Roanoke the performance of duties and responsibilities placed Chowan Hospital, Vidant Home Health & Hospice, by Hospital's Infection Control Policies. Submit in Vidant Medical Group) writing the names of each faculty member, faculty members' credentials, and contact information. Greenville, North Carolina Provide the Hospital with copies of current course outlines, course objectives, curriculum philosophy, and student evaluation forms pertaining to clinicals. Extend Hospital appropriate personnel adjunct appointments on the Schools teaching faculty where feasible and applicable. Students: Provide Hospital with copy of current immunization records. Complete Appendix A.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Complete an acknowledgement of understanding of the policies provided by the agency. View Point Health Undergraduate and Graduate Nursing Lawrenceville, Georgia Virginia Commonwealth University Nursing Students must complete Attachment A. Health System (VCU) Students MUST purchase their own professional liability insurance in keeping Richmond, Virginia with the amounts required by the Virginia Code Section 8.01-581.15, as amended. Virginia Mason Medical Center RN-BSN, MSN, Covers: RN-BSN, MSN, and DNP Students DNP Seattle, Washington USA/Faculty: Must provide student names, and relevant education and training at least four (4) weeks prior to clinicals (if less than 4 weeks, by fax immediately). Assure student is trained in blood borne pathogens.

Student: Student is responsible for supplying any additional information required by facility prior to their arrival. May be required to submit the facility's Contractor/Student Fitness for Duty Compliance Certification forms (provided by facility). Must obtain liability insurance in the amounts set forth by the facility, $1,000,000 per occurrence and $5,000.000 in annual aggregate ( as this amount is more than the University's coverage) and provide a valid certificate of insurance upon request by facility.

Vitas Healthcare Corp of Florida Graduate Nursing USA/Faculty: Submit to Agency at least 60 days prior to clinical experience a schedule to include, name of Daytona Beach, Florida student, dates and hours for each experience. Must also submit a course description and/or syllabus for each program at least 60 day prior to clinical experience of program. All student’s, and on-site faculty participating in educational programs under this Agreement shall have verified Hepatitis B vaccination, MMR and OT immunization, and annual tuberculosis screening. Shall assure that students have received training in universal precautions for prevention of HIV and other blood-borne infections, and any other safety and security training as might be required by law. Shall advise its students, and on-site faculty of the risk of infectious diseases and that Vitas is not responsible for exposure to infectious diseases.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Wake Forest University Baptist Medical MSN, DNP See Exhibit A-Facility’s Department of Nursing Policies Guidelines. Center and its subsidiaries and affiliates The starting and ending date for each including but not limited to Lexington Medical Clinical Experience shall be agreed upon Center and Davie Medical Center at least ninety (90) days before the Clinical Experience commences. A Winston-Salem, North Carolina written plan detailing the use of Facility, the personnel and resources to be involved, clinical objectives and level of student’s academic preparation shall be submitted to the Facility’s Coordinator of Education at least thirty (30) days before the Clinical Experience commences. Clinical Experience scheduling shall be subject to final approval by the Facility.

The Institution shall advise all participating students and faculty (on- site) members of the requirement to provide proof satisfactory to the Facility that each student has hospitalization, accident and injury insurance to defray the cost of care of any illness or injury that may be sustained by participating in any clinical training.

Clinical faculty (on-site) and students must have a satisfactory physical examination documentation form on file at the Facility prior to participation in the Clinical Experience. Additional on site requirements during the Clinical Experience may include participating in orientation, on site HIPAA and other training, submission to a TB test, submission of a criminal background check, a 10-panel drug screen, and proof of seasonal flu vaccine. WakeMed Nurse Practitioner USA/Faculty: provide Agency with at least 30 days advance notice of the Raleigh, North Carolina names of students and faculty who will participate in the clinical program. Students: Completed Exhibit B. Student’s must carry general liability insurance in the amounts of $1million/$3million. Must also have appropriate health insurance in compliance with hospital requirements. Walla Walla General Hospital RN-BSN, MSN, Walla Walla, Washington DNP Renewal in process-set to expire 8/31/2018 Walter Reed National Military Medical Center BSN, MSN, DNP Students must complete the Training Bethesda. Maryland Affiliation Agreement Addendum. Walthall General Hospital (also covers the BSN, MSN, DNP Please see Exhibit C for any additional requirements. Walthall Rural Health Clinic) Tylertown, Mississippi Walton County Health Department MSN, DNP Defuniak Springs, Florida

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Washington Health System RN-BSN, MSN, DNP A Clearance Letter which attests to information pertaining to the health status Washington, Pennsylvania of assigned students including the following: • Tspot or PPD within past 12 months with documentation of medical follow-up and chest x-ray for individual with positive test result. • Immunizations(1) tetanus/diphtheria in past 10 years, (2) rubella (German measles) immunization or adequate titer, (3) 2 rubeola (measles) vaccine doses administered to those persons born after 1951 or have an inadequate titer, (4) varicella (chickenpox) immunity by disease, adequate serological titer, or adequate titer (5) Hepatitis B administration/declination. • Affirming students are currently free from communicable disease. • Evidence of student’s current PA licensure, if applicable. • Evidence of students having had or provision for getting OSHA bloodborne pathogen and tuberculosis training. • Evidence of students having current AHA BLS Healthcare Provider Completion/Renewal status, if applicable. • Evidence of students having PA Patch criminal background check/PA Child Abuse History Registry Clearance/FBI clearance. e. A signed Washington Health System Affiliating Faculty and Students’ Handbook Acknowledgement form for each student. All students shall sign a WHS Non- Employee Confidentiality Statement. Washington Hospital Healthcare System RN-BSN, MSN, DNP Student: Please complete Exhibits C&D and return to the hospital. Freemont, California Washington Parish Emergency Physicians Nursing Programs Upon request, USA shall provide the current curriculum course objectives, and Group, LLC (preceptor agreement) syllabus of clinical program. Lafayette, Louisiana Students must have health exam before beginning clinicals with Preceptor. Students must obtain and maintain separate professional liability insurance (other than that through USA) in the amounts of $1million per occurrence $3million annual aggregate, and provide a certificate of insurance evidencing such coverage. Washington Regional Medical Center MSN, DNP USA/Faculty: Provide copy of course outlines and/or clinical objectives for a Fayetteville, Arkansas specific clinical rotation. Provide a list of names of students and faculty directing the learning experiences of each semester in experience. Student: Must complete a urine drug screen test. Must present to facility within

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered 7 days of commencement of their experience a copy of negative urine drug screen. Must provide a copy of criminal background check for the state in which the student resides.

Weed Army Community Hospital BSN, MSN, DNP At least 30 days before the beginning of and Nurse each training period, provide the names Fort Irwin, California Practitioner of the students eligible to be appointed, Renewal in process-set to expire the dates and hours for which training is requested, and the clinical activities in 10/11/2018 which training is requested. In addition, USA shall provide the Agency with the Practicum Requirements, a copy of the Course Goals and Objectives and applicable evaluation information. USA shall instruct each Student that the following will be adhered to and that such shall provide the following to the Chief of Education: Letter of Intent, Original BLS Certification to include Expiration Date, Original License/Certification (indicating State and Expiration Date), HIPAA Certification, Occupational Health Requirements, Copy of most recent Physical Examination, Copy of PPD (within 90 days), Copy of Hepatitis-B Series vaccine or titer, Copy of MMR vaccine or titer, Copy of Varicella vaccine or titer, Influenza vaccination within the past 12 months.

Wekiva Springs Center Nursing USA/Faculty: Provide the names and information pertaining to relevant clinical Jacksonville, Florida experience within a reasonable time before the beginning of clinical experience. Student: Must sign patient confidentiality agreement, which the agency will provide. WellMed Medical Group Nursing Angela Palacios San Antonio, Texas WellMed Student Preceptorship Program [email protected] 1-866-876-4512

Updated process: WellMed Student Preceptorship Process (WSPP) 1. Student Coordinator or potential student will reach out to The WellMed Student Preceptorship Program. 2. Student will be directed to the online request form at:

https://www.wellmedhealthcare.com/about- wellmed/careers-at- wellmed/rotationexternship-request-form/ 3. The student will fill out the online request form and submit to WSPP.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered 4. If a School Affiliation Agreement exist between the students School and WellMed, WSPP will proceed with the Application process. *If a School Affiliation Agreement does not exist, the student will not be able to precept with us until an agreement is completed between their school and WellMed. WSPP will ask student for School Coordinators’ information to further discuss the process of obtaining said agreement. All efforts to complete an application for the student will come to a halt at this point until agreement is completed. Please be aware, that the School Affiliation Agreement process can take at a minimum 6 months to complete. 5. The student will be instructed to secure a preceptor. Once this has been done, they are to contact us again to proceed with the Application Process. 6. Once the student provides WSPP with the secured preceptors’ information, WSPP Coordinator will provide the actual application, instructions, and a checklist for all required documents. 7. Upon return of completed application and all documents listed on checklist, WSPP will set up a telephonic orientation. WSPP Coordinator will go over the following: - Code of Business - Code of Business Conduct - Customer Relations - Standards Of Behavior - Definition of Discrimination - Definition of Harassment - OSHA - Environmental Safety/ Procedures - HIPPA - Confidentiality - Complaint Procedure - Public Relations 8. Once the telephonic orientation is completed, the student is ready to go into the clinic. Student/ Student Coordinator and Clinic Administrator will receive an email with the confirmation of completion of the Application process with anticipated start/end date. Under no circumstances, should a student be in our facilities until this entire process is completed Wellness Pointe Undergraduate Longview, Texas and Graduate Nursing Students WellPoint, Inc. (CareMore Health) AGACNP Faculty must send Education Verification Letter to agency prior to beginning of Indianapolis, Indiana clinicals.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered WellSpan Health (to include the following counties: Nursing Six weeks prior to clinical Faculty must Adams, Lancaster, Lebanon, and York) submit to agency the following: student list to include, dates, hours for clinical, York, Pennsylvania level of experience, learning objectives, and names of students. Please see Exhibit C Health Status Documentation. WellStar Health System, Inc. BSN, MSN, DSN, VERIFICATION OF INSURANCE MUST RN-MSN, DNP BE REQUESTED FROM THE USA Marietta, Georgia CLINICAL AFFAIRS OFFICE. This site WELLSTAR Employees Only is utilizing ACEMAPP for all Clinical Sites covered go to: Rotations. Call Clinical Affairs with any questions. https://www.wellstar.org/locations/pages/default.aspx USA Faculty, please see agency instruction letter. Only WellStar employees are eligible. Students must complete an orientation packet prior to beginning any clinical rotation. Faculty, please complete the organizational Learning form for each semester for each program at a Well Star facility (form available in the attachments folder). West Cancer Center Undergraduate and Graduate Nursing Germantown, Tennessee West Central Health District Undergraduate and Graduate Nursing Columbus, Georgia Students West Florida Hospital Nursing USA/Faculty: Complete Exhibit C- Attestation of Background Pensacola, Florida Investigation/Drug Screen Students: Complete Exhibit A and B. West Florida Medical Group Nursing USA/Faculty: Complete Exhibit C- Attestation. Pensacola, Florida (corporate Tallahassee, Student: Complete Exhibit A and Florida) Confidentiality Statement. West Georgia Health RN-BSN, MSN, Students: Must undergo a complete DNP physical examination (less than 1 year LaGrange, Georgia old), background check, and drug screening prior to clinicals. West Valley Medical Group, LLC Undergraduate and USA/Faculty: Complete Exhibit - Graduate Nursing Attestation. Caldwell, Idaho Student: Complete Exhibits A&B. West Virginia University, School of Medicine, Undergraduate Student: May be required to provide documentation of a satisfactory physical West Virginia University Hospital and and Graduate Nursing or health report and proof of such University Health Associates immunizations as facility may reasonably Morgantown, West Virginia require. Please complete the compliance checklist/attestation for each student. See all attachments. Western Mental Health Institute Nursing Programs Student: Complete Attachments B&C. Must have received a tuberculosis PPD Bolivar, Tennessee skin text within the past year. Western State Hospital—DSHS Mental USA/Faculty: May be required to submit Health Division the following information to facility: beginning and end dates of clinical, Olympia, Washington number of students, specific days, hours, and locations, learning objectives, performance expectations for students,

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered deadlines and format of the progress report and/or evaluation forms. Must provide curriculum and the professional and academic credentials of its faculty for the students.

Student: Must have yearly PPD TB testing or follow-up if student is ppd- positive. Must have background record from the Washington State Patrol and provide to facility. Wheaton Franciscan Healthcare-Southeast MSN, DNP Students and Faculty please see ALL detailed requirements. Faculty, please Wisconsin, Inc. see agency attachments within PUB Milwaukee, Wisconsin DOCs. White Memorial Medical Center Los Angeles, Nursing Please see Exhibit C-Code of Conduct. USA/Faculty: Provide HOSPITAL with California any documentation requested to facilitate the credentialing of Student(s) rotating at the HOSPITAL. Such documentation should be provided to the Nursing Education Department offices of HOSPITAL no less than thirty (30) days prior to the commencement of the Student(s) rotation. Such documentation may include, but not be limited to, current malpractice insurance coverage and any other forms required by HOSPITAL for credentialing purposes. Failure to provide such documentation within the abovementioned timeframe may delay the effective start date of the Student(s) rotation. Drug Screening: HOSPITAL will be provided with a drug screen on each referred Student, to incorporate a five panel urine test prior to each confirmation start date at the SCHOOL’s and/or the Student’s expense. This test must be done no more than two (2) week prior to the start of the affiliation. The five-panel urine test shall consist of screening for: cocaine, heroin, PCP, Marijuana and Methamphetamines. Per HOSPITAL request, all Student may be requested to undergo a blood test, urinalysis, “Breathalyzer” test or other diagnostic test under the following circumstances: Background Screening. SCHOOL shall conduct the necessary background check(s) to determine the proof of U.S. citizenship, name verification and presence of criminal activity and provide a copy of such background check to HOSPITAL two (2) weeks prior to the start of the Program. Students: must complete Exhibits A&B. Students must provide automobile liability insurance to Hospital, which complies with the California liability insurance requirements. Students must pass

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered medical examination at least once a year or otherwise required by California law. Surgical/TB Respirator Mask Fit Testing: Must have Surgical/TB Respirator Mask Fit Testing according to California law, The Joint Commission, and Manufacturer regulations for Student(s) participating in the Program at HOSPITAL, and a copy of the Surgical/TB Respirator Mask Fit Testing results shall be sent to HOSPITAL two (2) weeks prior the Program rotation start date. SCHOOL shall conduct Surgical/TB Respirator Mask Fit Testing at least once a year or as otherwise required by California law, The Joint Commission, any accrediting organization, and regulatory or administrative agency to which HOSPITAL may be subject. White-Wilson Medical Center, P.A. APRN Preceptors must be MD’s and assigned by Facility. Fort Walton Beach, Florida Agency contact: Brigitte Sullivan bsullivan@white- wilson.com

Student: Provide proof of OSHA and HIPAA education to facility. Maintain individual health and accident insurance while in the performance of agreement. William Beaumont Army Medical Center FNP Family Nurse Practitioner students (Agreement applies to only one trainee at El Paso, Texas a time).

William Carey University Undergraduate Hattiesburg, Mississippi and Graduate Willis-Knighton Health System (sites available MSN, DNP Student is responsible for their own personal health care expenses. in Louisiana, Arkansas and Texas) (Ark-La-Tex Student must have a Fit Test for the N95 Children's Clinic is NOT covered by the Willis- Respirator and is responsible for the cost Knighton) of test. Shreveport, Louisiana Students please see Flu Shot Memo and Declination of Seasonal Influenza Vaccine. Students must register within the agency's database -complete orientation packet and return all documentation to agency 21 days prior to clinical rotation (please see attachment).

Winn Army Community Hospital MEDDAC MS and DNP USA/Faculty: At least 30 days before the beginning of each training period, provide Fort Stewart, Georgia the name of the trainees to be appointed, the dates and hours for which training is requested, and the clinical activities in which training is requested. Wiregrass Clinic, LLC Nursing USA/Faculty: See Addenda 1&2 for duties students can/cannot provide. Dothan, Alabama Students: Complete addenda 4-6. Students must have health insurance during clinical rotation.

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Obtain written documentation from Students and staff prior to referring them to Facility: (a) a negative TB skin test within the past year or, in the event of a positive TB skin test, a chest x-ray within the past three (3) years; OR provide evidence of no TB disease per negative result of interferon- gamma release assay blood test (T-Spot or Quantiferon Gold) within twelve (12) months of student activity at facility; (b) a completed series of Hepatitis-B vaccine, having begun the series, or informed refusal of the vaccine; and (c) any other appropriate immunizations requested by Facility. Documentation for legally-required testing requirements noted. See Addendum 3. Ensure that Students are aware of the Substance Policy. See Addendum 4. Provide the Facility with a copy of each Student’s completed (1) Substance Policy Consent Form (See Addendum 4) and (2) Background Consent Form (See Addendum 5). The School may instruct the Student to provide the forms to the Facility; however the completed forms and results must be on file at the Facility before any Student is referred to the Facility. Ensure that the following background checks have been completed before referring Students to Facility (See Face Sheet to determine who will be responsible for the cost and actual performance of the background checks): Women & Infants Hospital Graduate USA/Faculty: Provide a schedule to Hospital 2-3 months prior to the start of Providence, Rhode Island the semester. Provide attestation that lists students, completion of health screening requirements (Exhibit A).

Student: Must complete Hospital Mandatory Orientation and/or comparable skill sets prior to their initial contact with Hospital. Must have current physical examination. A color blindness test may be administered when applicable to job function. Women’s Health Care of Western Colorado, BSN, RN-BSN, P.C. MSN, DNP Grand Junction, Colorado

Womack Army Medical Center MSN, DNP For MSN and DNP – No more than three (3) trainees annually. Faculty must Ft. Bragg, North Carolina contact Carla Heilman she can be reached at 907-8625, within 30 days in advance for each student placement.

Wuesthoff Medical Center/Rockledge MSN Students, Student: Complete Addenda 4 & 5. Must have received education regarding

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

Agency Name Programs Agency Requirements Covered Rockledge, Florida DNP-Nurse clinical safety, including OSHA blood Executive borne pathogens standards, and Students tuberculosis transmission prevention prior to clinical rotation. Must provide Florida RN Primary source verification of the current license.

Agency Name Programs Agency Requirements Covered XLHome, P.C. and XLHome NP USA Faculty please note: Written Objectives for agency’s review and comment may be requested. Northeast, P.C. Keep agency informed of hours and arrange for Elkridge, Maryland agency to evaluate student’s performance. Students must read and sign Exhibit B.

Agency Name Programs Agency Requirements Covered Yale New Haven Hospital Nursing USA/Faculty: Submit to Agency name, date of experience, verification of the current RN licensure New Haven, Connecticut status for each student at least 30 days prior to clinical experience. Contact: Laura Pallone-203-688-1047- [email protected] York Hospital Undergraduate and Graduate Nursing York, Maine

Agency Name Programs Agency Requirements Covered Zablocki VA Medical Center

Milwaukee, Wisconsin

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UNIVERSITY OF SOUTH ALABAMA COLLEGE OF NURSING September 14, 2018 Clinical Agency Affiliations and Locations

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