Download Student Application

Children’s Hospital, Boston
Department of Nursing
300 Longwood Ave
Boston, MA 02115
All forms must be submitted to:
Diana Dorci, Student placement Coordinator
Staff Development, Wolbach 201
Student Application
Name:
School:
School Address:
Street::
City:
Phone:
Home Address:
Street:
City:
Phone:
Dates of Practicum:
State
Zip:
Fax:
Email:
State
Zip:
Fax:
Thru
Email:
Hours per week:
Faculty/advisor:
School break/holidays:
Please submit the following with your application:
 Basic Life Support Certification (unless with faculty member)
 Completed Communicable Disease Screening
 Completed OSHA Blood Borne Questionnaire
 CORI check completed
Graduate/NP Students only:
 Student letter of intent
 Student objectives Course description
 RN License Verification
 Malpractice insurance
 Student Resume
Placement office only:
Instructor:
Preceptor:
Unit:
Children's Hospital
OSHA BLOODBORNE PATHOGEN TRAINING
QUESTIONNAIRE
Name:
Date:
Please check your response.
1. I am able to identify duties I perform that may expose me to a
blood borne pathogen.
2. I am able to list and locate protective equipment I need to
prevent exposure to blood borne pathogen
I am able to
identify duties I perform that may expose me to a blood
borne pathogen.
3. I am able to identify infectious waste and sharps and
located the proper place to dispose of them.
I am able to
list and locate the protective equipment I need to prevent
exposure to a Blood borne pathogen.
4. I am able to give an example of an exposure to a blood
borne pathogen and I know the correct way of reporting the
exposure.
5. I am aware that Hepatitis B Vaccine can prevent infection
with Hepatitis Virus. and:
I plan to seek immunization through my private doctor
and will bring a copy of his/her verification when I have
completed the three (3) inoculations.
I am already immunized. I will bring verification.
I have decided not to pursue immunization for Hepatitis B
even though I understand that I am at some risk of
contracting this disease. The reason for decision is:
economic, philosophical, other.
Revised 4/24/01
Yes
No