Participant Acknowledgement Form and Rotation Schedule

*This form must be completed by the learner*

Last Name  
First Name  
Email  
Phone Number  
Academic Program (eg., Nursing)  
School  
Faculty Advisor Name & Title  
Faculty Advisor Telephone  
Faculty Advisor Email Address  
Emergency Contact Name  
Emergency Contact Relationship  
Emergency Contact Telephone  
Emergency Contact Alternate Telephone  

The undersigned has applied to participate in a training program through Trinity Health - New England, Inc. (TH-NE) in Hartford, Connecticut. He or she understands that execution and submission of this Clinical Experience Participation Agreement is a pre-condition to commencing participation in the training program at TH-NE. Learners will not be eligible to engage in training at TH-NE until all forms have been received, reviewed, and approved. 

Prior to commencing training activities at TH-NE, he or she shall complete the New Learner Orientation and Onboarding Process required by TH-NE. This includes the following:

  • The Clinical Experience Participation Agreement – print from Step 2 Part 1, complete and return to your preceptor/coordinator
  • The Participant Acknowledgement Form and Rotation Schedule – complete electronically (below)
  • Learner Health Clearance Form – print from Step 3, have completed and faxed to Occupational Health
  • The Confidentiality and Non-Disclosure Statement – print from the New Learner Orientation Information Packet (Step 4), sign and submit to TH-NE preceptor/coordinator
  • The Code of Conduct and Corporate Compliance Plan Acknowledgement Statement – print from the New Learner Orientation Information Packet (Step 4), sign and submit to TH-NE preceptor/coordinator
  • Language Services Training Presentation Sign-Off Sheet – read the Language Services Training Presentation PowerPoint (Step 5), then print the sign-off sheet and sign and submit it to TH-NE preceptor/coordinator

Full Name:   

Date (mm/dd/yy):    [None] Select a Date Delete the Date 

 By checking this box, you hereby acknowledge that you have read and understand this Participant Acknowledgement Form and agree with the above conditions.

TH-NE site you are rotating at:  
Department you are rotating in:  
Program Coordinator at TH-NE:  
Your TH-NE Rotation Site Supervisor / Preceptor:  
Rotation Start Date:  [None] Select a Date Delete the Date 
Rotation End Date:  [None] Select a Date Delete the Date 

 

   

Please direct any questions about the form requirements to learners@stfranciscare.org