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Rehabilitation Student Clinical Placement Forms

Forms and Completion Verification

Students must print and complete the HIPAA form, the Minimum Necessary Use form and the Contact Information form. Bring a copy of a current CPR card. Provide vaccination and background check verifications as outlined below.

Completed forms and vaccination records or waivers need to be brought to the first day of the clinical experience.

The Clinical Instructor or Site Coordinator will verify these items upon arrival.

HIPAA, CPR & Contact Information

  • Student Statement of Confidentiality [PDF] – Please review and print this form; it is to be signed following completion of the HIPAA training module [PDF] 
  • Minimum Necessary Use Form / Protected Health Information Sheet [PDF] – Your use of and access to confidential information during the clinical experience is limited to what’s required by your job duties and assignments. Please sign and date this form.
  • Current CPR Card – Please bring a copy of your current CPR certification card with you to the first day of clinicals.
  • Student Emergency Contact Information [PDF] – Students’ emergency contact information will be kept with the department staff phone list. Please complete this form and turn it in to your Clinical Instructor on your first day of clinical experience.

Immunization Information

Please bring the following with you on the first day:

  1. Confirmation of negative TB skin test, QuantiFERON test, or negative chest x-ray for known converter
  2. Confirmation of vaccination for immunity for:
    • Measles/Mumps/Rubella
    • Diphtheria/Tetanus
    • Varicella
  3. Confirmation of Hepatitis B vaccination or signed waiver
  4. Confirmation of flu shot (for clinicals between October 1 and April 30, as outlined in Flu Shots for Students [PDF])

Background Check

Please bring the following with you on the first day of clinical experience:

  1. Confirmation of completed criminal background check

Evaluation Forms – After Clinicals

After completing your rotation, you are encouraged to submit feedback about your clinical instructor and the site or sites at which you trained.

Please print, complete and submit to your site coordinator at the end of the clinical experience:

Contact Us

Connect with a Rehabilitation Student Placement Coordinator today.

COVID-19

Vaccine Update

We’re vaccinating anyone in Illinois and Wisconsin who’s 16 and older – whether you’re our patient or not – with the Moderna and Pfizer vaccines. We’ve paused use of the Johnson & Johnson vaccine. See why.