Clinical Placement Health Declaration Form
Please complete the Clinical Placement Health Declaration Form before starting your placement. This form collects essential health information required for clinical placement participation.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Placement Site or Facility Name
*
Placement Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you experienced any of the following symptoms in the past 14 days? (Select all that apply)
*
Fever or chills
Cough
Shortness of breath
Loss of taste or smell
None of the above
Other
Have you had close contact with a confirmed infectious disease case in the last 14 days?
*
Yes
No
Are your immunizations up to date as required by your placement site?
*
Yes
No
Unsure
Please list any additional health concerns or relevant information (optional)
Submit Declaration
Should be Empty: