Faculty Forms / Documents

Whether you are placing students with St. Mary's for the first time or you have placed students with us many times, please read through this entire list of forms and documents. Some requirements have changed.

Missing, late, or inaccurately completed application and registration materials may jeopardize your students' clinical rotation.

The first time you place students with St. Mary's as a clinical instructor:

Print the forms listed below, complete in ink, and submit to St. Mary's student placement coordinator in Nursing Support Services by mail or fax.

• Clinical Instructor Profile
• Pre-requisites for Student Affiliation  
• ID Badge Acknowledgement and Deposit Form Student/Instructor
• Background Check (FCRA) Authorization
• Vehicle Registration Form - Instructor (also required if you change vehicles)
• Conflict of Interest Disclosure
• Confidentiality Agreement 
• Standards of Business Conduct: Student
• Women & Children Services Red ID Badge Acknowledgment
• Student & Instructor Online Orientation Acknowledgment
  On this acknowledgment form, you will indicate that you have read and understand these standards, agreements, and orientation modules:
  • Student Nurse Experience Guidelines Standard
  • Clinical Unit Descriptors
  Student Nurse Online Orientation modules:
  • Hospital Mission and Goals/Commit to Care
  • Infection Control
  • Environment of Care
  • National Patient Safety Goals
  • Organizational Responsibility Program (ORP)
  • Dress and Grooming Standards
  • Drug-Free Workplace
  • Anti-Violence
  • Harassment
  • Ethical and Religious Directives
  • Patient Rights
  • Parking Policy and instructions

Submit the following items initially and when there are changes and/or renewals:

• Clinical Instructor Profile
• Vehicle Registration Form - Instructor (required if you change vehicles)
• Basic Life Support card copy
• Professional licensure/registration copy

Re-submit the following items annually:

• Conflict of Interest Disclosure
• Confidentiality Agreement 
• Standards of Business Conduct: Student