Instructor 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. *

Today's Date *

First and Last Name *

email Address *

Phone Number *

Are you a KRHS employee? *
Yes   No   Previous employee  

If yes, in which KRHS department do you work?

School Name *
FVCC    MSU    SKC    Other   

What program do you teach? *

What is your official title? *

Please list the college course number(s) you will be instructing. *

Season Quarter or Semester *
Spring    Summer    Winter    Fall   

Quarters or Semester *
Quarter    Semester   

Year
2020    2021    2022   

What date will the students begin at KRH? *

What date will the students end the rotation at KRH? *

How many hours do the students need to acquire for this clinical rotation? *

Emergency Contact Name *

Emergency Contact Phone *

Vehicle Information #1 Make: Model:Color

Vehicle Information #2 (if necessary)

I have reviewed and submitted the Meditech, Point of Care and Pyxis Training links for this semester/quarter. *
Yes    No   

Will your students need POC (Point of Care) training this term? *
Yes    No   

Will your students need Pyxis training this term? *
Yes    No   

Will your students need Meditech training this term? *
Yes    No   

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 Kalispell Regional Healthcare (KRH) 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 EDU800 Policy. *
Yes   

I have read, understand and agree to comply with the GNNC780 Nursing Student Clinical Rotation Policy *
Yes   

I understand and agree to allow my immunization records and background check to be shared between my school and Kalispell Regional Healthcare. *
Yes   

Medical/Dental Treatment
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 Kalispell Regional Healthcare (KRH).



Yes  

I hereby waive any liability on the part of KRH, 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  

Are you a new or returning instructor at KRH? *
New    Returning   

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

Other Comments or Information

Type the first and last names of all your students for this semester/quarter. This will be used as a roster for training.