Student Request for Clinical Clearance

Site Name *

Site Contact Person Name *

Site Contact Phone *

Site Contact Phone, part 1

Site Contact Phone, part 2

Site Contact Phone, part 3

ext.

Site Contact Phone, part 4

Site Contact Email *

Do you have copies of the clearance documentation for CSUF to complete? *

Some clinical sites will provide students with copies of the clearance forms and ask that they are given to a University representative. Please indicate if you have been given such forms.

Yes

Please link or upload copies of the forms your clinical site is requesting be completed and signed by a CSUF representative here.

Do you have a file, a URL/link or both? *

Form URL/Link *

File *

More information

Files must be less than 100 MB.
Allowed file types: gif jpg jpeg png tif txt rtf html pdf doc docx xls xlsx.

Date of Last Physical Exam *

Month

Day

Year

Do you have a CPR Certificate? *

Yes

Upload CPR Certificate *

More information

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png tif pdf doc docx.

Clinical Activity Proposed Start Date *

Month

Day

Year

Clinical Activity Proposed End Date *

Month

Day

Year

Student Request for Clinical Clearance

After submitting this form, please wait for further instruction from a CICE Representative.

DO NOT begin your internship until you have been properly cleared to do so.