Visiting Learners Form

Guiding principles for Academic Year 2022-2023 are to protect patients, faculty, staff, and learners as well as to maintain a safe and effective learning environment. Clinical rotations for learners enrolled in Wake Forest University School of Medicine degree-granting programs will be prioritized. Please complete this entire form and a response will be provided as soon as possible. Also note that this is a smart form and will load more form fields based on your selections.

Please complete the following information and a response will be provided soon.

Program Name? Name of individual submitting request? Email address for individual submitting request? Telephone number for individual submitting request?

Learner Needs Information

WFBH will provide necessary mask(s) and/or gloves based on clinical assignment.

Learner type for this request? Medical Students Physician Assistant students Nurse Anesthesia students Advanced Practice Nursing students Nursing students Allied Health students Observation or Shadowing Other

Other

Would you want your learners to work with isolation patients if there is an adequate supply of PPE to allow this? Yes No

Please provide the average number of learners/week in areas of isolation Dates when learners are requested to be in the Atrium Health Wake Forest Baptist system Number of learners/week (average)?

Number of learners/week (average)?

Dates when learners are requested to be in the Atrium Health Wake Forest Baptist system? Number of learners/week (average)?

Home Institution Questions

These questions refer to the institution where the student is enrolled in their degree granting program.

Does the home institution have policies/practices in place for learners to self-monitor before starting each clinical experience? Yes No

Does the home institution have policies/practices in place if the learner has an exposure? Yes No

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Translation to Care

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Visiting Learners Form

Please complete the following information and a response will be provided soon.

Learner Needs Information

Home Institution Questions