Instructor Personal Information

Please fill out this form completely.

Effective Monday, May 18, 2020, we have opened up our student educational experiences to a limited number of students and trainees.
Information will continue to evolve and we will update this information as it becomes available. Thank you for your understanding.

COVID-19 Student, Instructor and Trainee Requirements
Due to COVID-19 precautions, all students, trainees and instructors must carefully review the forms and information provided below.
We are advising no travel for 14 days before a rotation begins as the best approach to an on-time start date.  If you plan to travel in a high-risk manner prior or during your clinical time at KRH determined by the documents below,

Today's Date *

By signing my name below, I attest that at this time I can answer NO to the following 4 questions. Should at any time, I develop one of these symptoms, travel outside of the KRH Personal Travel Restrictions, or come in contact with a known or suspected case of COVID, I will notify my Clinical Instructor, KRH Employee Health Services at hcatlett@krmc.org or 406- 751-6549 and the Student Coordinator at KRH immediately, for next step instructions.


COVID Attest Signature *

Do you have fever or chills, cough, sore throat, shortness of breath or difficulty breathing, new loss of taste or smell, unexplained new onset of fatigue, body aches, headache, nausea or vomiting, diarrhea, congestion or running nose? *
No  

Do you have a temperature? (If Temp = 100 call or email KRH Employee Health Services at hcatlett@krmc.org or 406- 751-6549 and cannot attend any clinical experiences until cleared through KRH Employee Health Services and the Student Coordinator Office). *
No  

Have you had a recent travel history that is outside of the KRH High-Risk Personal Travel Restrictions? See the Student, Instructor and Trainee Travel Restrictions and Quarantine/Screening Instructions Document above. *
No  

Have you had close contact with anyone known or suspected to have COVID-19? (within 6 feet of someone for at least 15 minutes without a mask) *
No  

I have reviewed the information provided regarding COVID-19 requirements and attest that I understand and will comply with all the information stipulated. I know I need to report any high-risk travel completed within 14 days of my start date, any high-risk travel plans during my rotation, any symptoms, or any contact with anyone known or suspected to have COVID-19.



Yes  

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 and understand the Acknowledgement of Resources *
Yes   

I have read and understand the Confidentiality Acknowledgement *
Yes   

I have read and understand the Disclaimer for Intellectual Property. *
Yes   

I have read and understand the EDU800 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.