Clinicals in Southwest Virginia

Contact Lewis Gale Medical Center location to ensure clinical rotations, observation or practicum is allowed. No shadowing is allowed.

1. Complete Addendum A
2. Complete Addendum B
   Give the completed forms to your designated clinical coordinator
   We must receive your completed forms at least 21 days before your first day at HCA. Failure to comply with this request could affect your clinical rotation at HCA.

Please Note: Prior approval from the facility must be obtained before filling out any of this information.

All students entering HCA for clinicals that involve direct patient contact, or for observation only, must complete all of the following:

1. Read the Student Education Tool.
2. Complete the online Student Education Tool Post-test. Minimal passing score is 80%. You will receive an e-mail notifying you of your test results. If you passed the test, print a copy of your notice and give it to your designated faculty member. If you did not achieve a passing score, review the Student Education Tool and retake the Post-test for a passing score.
3. Print, read and sign the HCA Confidentiality and Security Agreement. Give the signed copy to your designated faculty member.
4. Print, read and sign Exhibit A: Statement of Responsibility and Exhibit B: Protected Health Information, Confidentiality, and Security Agreement. Submit the completed forms to your designated faculty member.

5. All students are required to submit a release form for a background check regardless of the hospital. To access the release form, go to:
   https://weborder.precheck.net/Release/release1.aspx.

   1. For LewisGale Medical Center students, enter the code 7575
   2. For Alleghany students, enter the code 2366
   3. For Montgomery Regional students, enter the code 9464

   Follow the additional instructions listed on the website to complete the form.

6. For Pulaski students, print and complete this Student Background and Verification Order Form.
7. Print and fill out the Parking Application and give it to your designated faculty member (this application applies only to students at LewisGale Medical Center).
8. Read the Substance Use in the Workplace Policy, print out the acknowledgment form and sign. Submit all forms to your designated faculty member.
9. Flu Vaccine Declination Form
10. Read HCA Healthcare Code of Conduct and complete acknowledgement card.

All downloadable material is in Adobe PDF format, and requires Acrobat Reader to open. Download a free copy of Acrobat Reader.

All faculty entering HCA for clinicals that involve direct patient contact, or for observation only, must complete all of the following:

• Attestation for Employee Health and Other Student Compliance Requirements
• Attestation of Satisfactory Background Investigation Report
• Education Tool Post-test
• Flu Vaccine Declination Form