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

Occupational Health

I confirm I have my University Occupational Health Fitness for Practice Certificate. ^*

Yes No

I have health conditions or disability that require workplace adjustments or restrictions and consent to share my University Occupational Health report. ^*

Yes No

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