Instructor Personal Information

Please fill out this form completely.

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
2015    2016    2017    2018    2019    2020    2021    2022    2023    2024    2025   

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    No   

I have read and understand the Acknowledgement of Resources *
Yes    No   

I have read and understand the Confidentiality Acknowledgement *
Yes    No   

I have read and understand the Disclaimer for Intellectual Property. *
Yes    No   

I have read and understand the EDU800 Policy. *
Yes    No   

I understand and agree to allow my immunization records and background check to be shared between my school and Kalispell Regional Healthcare. *
Yes    No   

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.