By checking the box for each document I, hereby certify that the following documents are on file at the contracted college office. The school will be responsible for submitting any requested document for Kindred, inspectors and surveyors upon request. For questions please contact the Student Programs Department at scheduleyourclinical@kindred.com.
Background Check Results
Drug Screening Verification
PPD or CXR Negative Test Results
PPD or chest Xray: Date completed:
Hepatitis B Vaccination Declination/Consent (Titer)
Influenza Vaccination (flu shot seasonal)
Measles
Mumps
Rubella
Varicella
Tdap (one time administration) or Tetanus
Covid
Vaccination Card
Patient Confidentiality Agreement
OIG/GSA
*If you are unsure if you meet all the above requirements please connect with your faculty coordinator to verify, prior to submitting your registration.
The student does hereby certify that he/she is enrolled in and does not presently have a communicable disease or communicable health problem that might or could jeopardize patient or employee health at . hereby agrees to notify Kindred if he/she contracts or becomes aware that he or she has a communicable disease or communicable health problem that might or could jeopardize patient or employee health care at .
Dated this the 23 day of October, 2021.
Checking this box indicates that the information provided is correct and that I agree to the above information.
