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Kalispell Regional Healthcare

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Affiliation Agreement

A current affiliation agreement needs to be in place between KRH and the employee's employer to move forward with educational placements for training rotations. Please contact us as soon as possible to ensure an agreement is current and in place well in advance of an educational experience. This cannot be done by the individual departments and must be approved by the Student Affiliations department.

Paperwork, Documentation and Requirement Information for Educational Training Experiences

1a. Review this Acknowledgement of Resources, Confidentiality Acknowledgement and Disclaimer for Intellectual Property document before you continue.

1b. Review EDU800 Policy

1c. Review the Western MT Student Orientation/Requirement Manual

2. Fill out the Personal Information Form below. This will need to be filled out prior to the beginning of any and every rotation and/or experience. This form will be sent directly to the Kalispell Regional Healthcare Student Coordinator when you hit the submit button.

Personal Information Form to Begin Clearance Process

Hands On Trainee Personal Information Form for Clearance at KRH

Background Check Information

1. Submit a copy of a background check along with the Background Check/Release Form or just a copy of the Background Check/Release Form filled out by the health care facility with the date the background check was cleared and signed by both the trainee and the training site representative. If you choose the latter, there is a chance we will request a copy of the original background check for auditing purposes.

2. Please check the Office of Inspector General (OIG) http://exclusions.oig.hhs.gov/ and the national sexual offender registry search http://www.nsopw.gov/en-us and send copies of the clear status for each trainee.

Immunization and Communicable Disease Record Documentation Required

MMR (measles, mumps, rubella)
2 official records receiving shots
OR
Positive results from a titer for each (measles, mumps, rubella) showing immunity.
 
Varicella (chickenpox)
Record of two vaccinations      
OR

Positive titer results showing immunity
OR
If the trainee has recollection of having the disease. They will need to provide documentation in writing by filling out the Chickenpox/Varicella Affirmation of Recollection. It must be signed and dated with the approximate date or age the student had the disease. If one of the other two requirements above has been met, this will not need to be filled out.
 
Hepatitis B
Record of 3 shot vaccination series and titer with reactive or positive results
OR
A titer with reactive or positive results
OR
Student must have documentation they have started the series of 3 shots and a get a titer after the vaccinations.
OR
Can be declined but trainee must sign a Hepatitis B Vaccine Declination.
 
Tetanus w/ Pertussis (Tdap)                ***One record required in the last 10 years***
Required **Please note: this must be the Tdap (tetanus w/ pertusis) not td (tetanus diphtheria) vaccination.
 
Record of Flu shot                                 *****Yearly vaccination is required.******
If trainee will not be doing clinical during flu season, this shot will not be required
Keep in mind if shot is not required at the beginning of the rotation, but the rotation carries over into the next flu season, the student will be required to obtain the shot.
 
TB (PPD-tuberculosis)
Record two negative TB skin test in the last 12 months (If the test is positive, a chest x-ray required.)
OR
Negative Quantiferon TB blood test.
OR
Fill out Positive Responder Form. Ask the ORGANIZATION for this form if you have a positive test.
AND
Each year a trainee attends they must fill out a TB questionnaire provided by the ORGANIZATION. This questionnaire will then be sent to the ORGANIZATIONS’ appropriate department along with a copy of the original negative TB test to be reviewed and a determination.

Parking at KRH

Our parking space is limited so we ask that you park in the Student Parking during day shifts and in the Employee Parking area for night shifts. Please help us save parking for our patients and thier families. Click here for the parking map.

Any documents that need to be filled out (not including the documents that were for review only) will need to be returned to the KRH Student Coordinator at least 30-60 days prior to the start of a rotation. Feel free to scan and email the documents or if you prefer you can fax them to the secure fax line in the Student Coordinator's office. The contact information is below.

After all your requirements have been turned in and approved by the Student Coordinator, set up an appointment, in advance to be issued your Trainee ID badge.

Contact Information

Monica Peterson
Student Coordinator
Phone: (406)756-2713
Fax: (406)756-3693
Email: monicapeterson@krmc.org

The Student department office hours are 8:00 AM - 3:30 PM, Monday - Friday. You can also make an appointment from 7:00 AM - 8:00 AM and 3:30 PM - 5:30 PM to fit your schedule. The department is normally closed for national holidays.

The Student Affiliations department office is located on the second floor of the Administrative Office Tower, room number 240.