Student, Instructor, Trainee and Resident COVID-19 Attestation Updated 11/17/2020

Fill out this form completely and click submit when done. If you do not get a message that states "Thank you for completing this form." It may not have been submitted. You should also get a confirmation email at the email address you provide below if typed in correctly.

If you have any questions please contact the Student Affiliations Department at Kalispell Regional Healthcare.

I am a(n) *
Student    Instructor    Trainee    Resident    Other   

If other, please explain.

First and Last Name *

email Address *

School Currently Attending/Instructing *

Program *

I attest that I will stay at home if sick, notify my instructor, email my KRH Student Coordinator and will call Employee Health Services (406) 751-4189 on the first business day of onset of any one of the symptoms below related to COVID-19. *

I attest I will maintain social distancing while eating in breakrooms or lunch areas. I will wear a mask in these areas when not eating or drinking. *

I attest I will wear a mask and eye protection while at KRHS as defined by the protocols for my scheduled clinical area. *

I attest I will notify Employee Health Services (406) 751-4189, my instructor or school DON immediately and email my KRHS Student Coordinator if I come in contact with a known or suspected case of COVID-19 at KRHS or outside of KRHS and I was not wearing proper personal protection. *

I attest I will follow Employee Health Services (406) 751-4189 directives when allowed back to clinicals after an exposure. *

At this time, do you have temperature >100? *

At this time, do you have any new onset of symptoms such as chills, cough, sore throat, shortness of breath or difficulty breathing, loss of taste or smell, unexplained new onset of fatigue, body aches, headache, nausea or vomiting, diarrhea, congestion or runny nose? *

By typing my full name in the box below, I attest to all the above. Effective date version 11/17/2020. *