Logan Health Student/Trainee/Resident Personal Information

 

Please fill out this form completely and to the best of your knowledge.
 

Please type your name below attesting that you have read, understand and agree to comply with COVID-19 Student, Instructor, Trainee and Resident Requirements and have or will complete the current Student, Instructor, Trainee and Resident COVID-19 Attestation. *

You can find the most up-to-date COVID-19 website and Attestation Form at https://www.logan.org/krhc/about/student-affiliations/covid-19


First and Last Name *

Today's Date *

Are you a new or returning student, trainee or resident at Logan Health? *
New   Returning  

email Address *

Phone Number *

Please enter your Date of Birth *

Upload a current, conservative, professional photo for your Logan Health ID badge, if you have not already sent it or have a badge. Please make sure the photo follows the HR530 Dress Code Policy that can be found on the Student Website. No hats or sunglasses are allowed in the badge photo.


Are you a current Logan Health employee? *
Yes   No  

If so, where? If not, type N/A *

Have you ever had Logan Health computer access under a different name? *
Yes   No  

If yes, name computer access was under if no, type N/A? *

Will you be over the age of 18 when you begin your student experience? *
Yes   No  

School Attending or Residency Program *

Program Enrolled In *

What academic rank is this program? *
Non-Credit   Certificate   Licensure Training   Associate of Applied Science   Certificate of Applied Science   Associate of Arts   Associate of Science   Bachelor of Arts   Bachelor of Science   Master's Degree   Doctorate   Medical Doctor (MD)   Doctor of Osteopathy (DO)   Physician Resident  

What is the approximate date you are scheduled to complete this program? *

Logan Health Department(s) you will complete your educational experience. *

Please list the college course number(s) you will be attending for clinicals.

Rotation Start Date *

Rotation End Date *

What is the minimum number or hours you need to complete for this rotation, this semester/quarter? *

Advisor, School/Residency Contact or Instructor Name *

Advisor, School/Residency Contact or Instructor email *

Advisor, School/Residency Contact or Instructor Phone Number *

Logan Health Preceptor Name *

Emergency Contact Name *

Emergency Contact Phone *

Vehicle Information #1 Make: Model:Color:Year:State:License Plate # if known. *

Vehicle Information #2 (if necessary)

Acknowledgment that I have read and understand the LH Code of Conduct

I agree to obey all federal, state and local governmental laws and regulations at all times. If I am not certain about LH's policies, or about the law, it is my responsibility and my right to get advice from my supervisor, human resources, any management personnel, general counsel or the compliance officer.

I agree to comply fully with the Compliance Program guidelines contained in the Code of Conduct document. I understand that compliance with these guidelines is a condition of my association with LH. Likewise, I understand any failure to report a violation (even if the violation is committed by another individual), can result in disciplinary action, up to and including termination of my student experience. I also understand that LH reserves the right to occasionally amend, modify and update these Compliance Program guidelines.

I also acknowledge that the Code of Conduct is only a statement of principles for individual and business conduct and does not, in any way, constitute an employment contract or an assurance of continued association.


My signature on this form acknowledges that I have reviewed the Logan Health Code of Conduct and agree to abide by its contents. Please type your full name. *

I have read and met, or will meet, prior to my start date, all the obligatory immunizations, background checks, documents and all other requirements mandated by Logan Health in the orientation manual. *
Yes  

I have read, understand and agree to comply with the Acknowledgement of Resources *
Yes  

I have read, understand and agree to comply with the Confidentiality Acknowledgement *
Yes  

I have read, understand and agree to comply with the Disclaimer for Intellectual Property. *
Yes  

I have read, understand and agree to comply with the Security Codes and Procedures *
Yes  

I have read, understand and agree to comply with the EDU800 Policy. *
Yes  

I have read, understand and agree to comply with Dress Code Policy HR 530d *
Yes  

I attest I have reviewed and understand the current Corporate Compliance Program PowerPoint. *
Yes  

I understand and agree to allow my immunization records and background check to be shared between my school and Logan Health and all its entities as needed for my student experience clearance. *
Yes  

I agree to allow my immunizations and background check to be shared between Logan Health entities as needed for the clearance process. *
Yes  

Medical/Dental Treatment Agreement
I hereby give my consent, in the event of injury or illness, for emergency medical/dental treatment, hospitalization or other treatment as may be necessary for my welfare by a physician, dentist, licensed nurse and/or other hospital employee during all periods of time in which I am participating as a student/trainee/resident at Logan Health (LH).



Yes  

I hereby waive any liability on the part of Logan Health, its directors, trustees, agents and employees arising out of such medical/dental treatment. I also agree that I am responsible for any charges that may be incurred for such medical/dental treatment. *
Yes  

Signature: The information contained on this form is correct and complete to the best of my knowledge. Type your name in the box below to certify your agreement to all the above. *

Other Comments or Information