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