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.

Prior to submitting, please ensure you have provided the relevant ID documents as detailed towards the end of the form.

Personal Details

Surname

Forename

Title

Known by

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

Date of birth

National Insurance number

Current incoming placement details

School

Year

Block

Placement Site

William Harvey Hospital Queen Elizabeth Queen Mother Hospital

Current Placement/Specialty

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

Pre-arrival questions

Do you have an existing smartcard?

Yes No

Smartcard number

I have completed viewing the Clinical Induction Slides Part A

I have completed viewing the Clinical Induction Slides Part B

I have completed viewing the Managing Stress around COVID-19 slides

I have completed viewing the EKHUFT PPE Donning and Doffing video

I have completed the health declaration form and returned it to EKHUFT Occupational Health Department

I have watched Libraries induction video

I have watched EKHUFT Hospital tour video (QEQM/WHH)

Have you completed Allscripts PAS/Sunrise Training?

Yes No

Have you completed ILS?

Yes No

I have completed my ILS and the date is:

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

Date of arrival

Date when you would like to vacate

Any Dietary requirements

Any other information

Your ID and documents

1 x clear passport size photo and 3 x forms of ID will be required to be able to prepare your Smartcard. This must include at least one of the following ID documents:
- 1 x photo, with 2 x name and address
- or 2 x photo with 1 x name and address

Photo requirements:
• Photo must be clear, with no flash reflections and no 'red eye'
• facial expression must be neutral
• must show both edges of the face clearly and must show a full front view of face and shoulders, squared to the camera.

ID requirements (photo ID, and, name and address):
• Photo ID must include passport/driving license or valid ID/resident card.
• Statement must include full name and address of were currently residents, must be within the last 3 months or if council tax then this years period.
• NO Mobile phone statement will be accepted.

Your photo and documents

Drop files here or click to upload

Please upload your photo and ID documents - you can upload multiple files through this upload field.

For the purposes of the Data Protection Legislation (General Data Protection Regulation as well as any other laws, regulations, standards and codes relating to data protection), I consent to the photographer and EKHUFT Medical Education to storing and using copies of the photographs and contact details for the purposes described. Registration as a student and attendance at or participation in classes at EKHUFT constitutes an agreement by the student to the hospital’s use and distribution (both now and in the future) of the student’s image or voice in photographs, videotapes, electronic reproductions and other EKHUFT activities. I understand that images on websites can be viewed throughout the world and not just in the United Kingdom. I understand that some images may be kept permanently once they are published and be kept as an archive of EKHUFT Medical Education.
The personal data collected on this form will be held securely and will only be used for administrative purposes. EKHUFT is committed to processing information in accordance with the General Data Protection Regulation.

I give my permission for my image to be used as described above.

Yes No

I agree to any copyright residing with the EKHUFT team.

Yes No