Undergraduate Students Pre-arrival Checklist

Before completing this form, please ensure you have completed all required induction resources E.g., Clinical Induction slides, induction videos etc.

Personal Details

Title

Forename

Surname

Known by

Date of birth

National Insurance number

Email address

You must supply your college email address, we are not permitted to use a private email address.

Telephone

Start date of your placement

End date of your placement

Current incoming placement details

School

Current Placement/Specialty

Year

Block

Placement Site

William Harvey Hospital Queen Elizabeth Queen Mother Hospital

Previous and future placements

Previously on placement in EKHUFT?

Yes No

Any future planned placements?

Yes No

Block for future placement

Placement/Specialty for future placement

Health Risk Assessment Score

I have completed the medical school COVID risk assessment and I have been cleared to commence clinical placement

Other

Will you be bringing a car to EKHUFT?

Yes No

If so, will you be happy to drive to other sites?

Yes No N/A

If so, are you happy to take a passenger?

Yes No N/A

Do you require accomodation?

Yes No

(Not applicable to KMMS medical students, please select no)

Date of arrival

Date when you would like to vacate

Any Dietary requirements

Any other information