Forms

Student Orientation – Policy Verification Form

Department of Physician Assistant Medicine

Student Policies Acknowledgement

 

I hereby acknowledge the following:

 

          • I have reviewed the Student Policies as outlined by the Department of Physician Assistant Medicine in the document at the URL below.
          • I have been afforded the opportunity to ask questions relating to information contained in Student Policies.
          • I understand and agree to abide by all policies and procedures as outlined in the student policies.
          • I understand and agree that I must meet the Technical Standards at all times while enrolled in the program and that I will notify the program immediately if I fail to meet the requirements at any time.

 

URL for the Physician Assistant Program Student Policies

https://www.frostburg.edu/programs/graduate-physician-assistant/welcome.php

 

Student Signature: __________________________________________

 

Student Name:              _____________________________________________

 

Date: ____________________________________________________

 

Form 2

Code of Conduct Acknowledgement:
FSU Community Standards Policy Statements

Department of Physician Assistant Medicine

 

 

I hereby acknowledge that I have read, and will abide by, the Frostburg State University Community Standards Policy Statements, as outlined by the Division of Student Affairs in the document at the URL below:

Community Standards Policy Statements Booklet

 

Student Signature: _______________________________________

Student Name: _______________________________________

Date: _______________________________________


Form 3

Release of Student Information Form

 

IMPORTANT: The Frostburg State Department of Physician Assistant Studies PA program is required to provide specific student information to the sites in which you will have a clinical experience. The following information may be required by clinical sites:

 Urine Drug Screen

 Tdap Booster

 MMMR

 Varicella

 Hepatitis B

 TB

 Flu Vaccine

 Criminal Background Check

 Professional Liability Insurance

 

RELEASE

I authorize the Department of Physician Assistant Medicine at Frostburg State University to forward my health information from Certifi as described above, to Student Coordinators, Office Managers, and other clinical site employees in connection with my participation in clinical experiences in the PA program.

 

Print Name: ________________________________

 

Signature: _________________________            Date: ____________


Form 4

Frostburg State University DPAM Notice of Incident Report Form 

 

Report Date________________  

Last Name: _______________________ First Name___________________________________  

Address______________________________________________________________________   

Supervisor/Clinical Instructor: ___________________________________________________  

Date of incident: _______________________ Time of incident: _____________________  

Facility and specific location of incident: ____________________________________________  

Job description (description of general duties): _______________________________________  

Potentially infectious material involved (e.g. blood etc.): ______________________________ 

Source of potentially infectious material (e.g. needle-stick, cut, bite etc.) ________________ 

Circumstances surrounding exposure (e.g. work being performed) ________________________ ______________________________________________________________________________  

Route of exposure (e.g. stick, splash, etc.)____________________________________________ ______________________________________________________________________________  

How exposure occurred (e.g. equipment malfunction) _________________________________ ______________________________________________________________________________  

Personal protection equipment worn at time of incident ________________________________ ______________________________________________________________________________  

Actions taken at time of incident (e.g. soap/water clean-up, reporting etc.) _________________ ______________________________________________________________________________ ______________________________________________________________________________  

Recommendations for avoiding repetition: __________________________________________

 

 

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