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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