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Facility Specific Documents
Check-Off Sheet
For:
Children’s Hospital Los Angeles (CHLA)
Print this check-off sheet, sign & date, and return with your documents.
Important Note: Carefully read and follow the steps listed below. Scan and Email all of your completed documents,
including this check-off sheet, to: [email protected] (PDF is preferred, but jpeg files will also be accepted).
We do not recommend sending in hard copies, however if you wish to submit paper documents, turn them into the main
Nursing Office (EC-190). We will only accept COPIES of your documents. Please submit your copies in an envelope with
your name, CWID #, and a phone number written on the outside.
KEEP ALL OF YOUR ORIGINALS until the end of the semester.
PART ONE:
 Make sure that ALL of your documents are uploaded and approved in your Certified Profile
account (as we will need to send the dates of your titers, physical exam, etc. to CHLA on your behalf).
 Orientation Booklet: Read over all 73 pages thoroughly (do NOT print)
 Confidentiality of Information: Signed and dated (print last page only)
 Trainee Role in ENVIRONMENT of Care: Signed and dated (print last page only)
 HIPAA Competency Test: Completed, signed and dated (print last 2 pages only)
 Social Computing Policy: Read over thoroughly. (5 pages, do not print)
 Social Computing Policy Acknowledgement: Signed and dated (print 1pg)
 Social Media “Keep Your Status Healthy”: Reviewed/ Read only (1 pg)
After you have completed the requirements above, please submit the 5 filled-in pages (do not include the
read-only forms) to [email protected]. Please note: Typed-out Signatures will NOT be accepted.
PART TWO:
This part is only to be completed once instructed to do so by the School of Nursing. You will be issued a CHLA ID number
which you must use to complete the 2 forms below:
 Identification Badge Application: Filled out, signed and dated
 CHLA Parking Application: Filled out, signed and dated
Last Updated: June 2015
(Continue to Page 2)
Facility Specific Documents
Check-Off Sheet (Page 2)
Children’s Hospital Los Angeles (CHLA)
For:
Print this check-off sheet, sign & date, and return with your documents.
(Continued…)
Once you have completed your ID Badge and Parking forms you will need to submit both of these to the
Parking office. The CHLA Parking Office is located at 4601 Sunset Blvd., Los Angeles CA 90027 (across the
street from the Hospital). All students will be assigned to an off-site parking lot for free with continual
shuttle service to and from the hospital. For those students who have weekend rotations or if the rotation
starts or ends in the evening you will need to be assigned to an on-site parking lot since the shuttles do not
run at these times. These lots have a minimal fee.
At the end of your rotation or preceptorship, your ID badge and parking pass MUST be returned to the
Parking Office – no exceptions!
I have reviewed all instructions and materials, as well as verified and completed all requirements listed above,
that are specified by the facility I will be attending.
Name (print): ___________________________________________________________________
Signature: ______________________________________________________________________
Date Submitted to CSUF SON: _______/________/____________ For Semester: _____________
Last Updated: June 2015
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