UMMC Affiliated Students Application
Request Academic Affiliations UMMC Coordinator Epic Administration Students List

Affiliated Program Coordinators
Thank you for your interest in the University of Mississippi Medical Center. Programs with academic affiliations with UMMC should use the form below to request placements for students who are enrolled in the affiliated programs in good academic standing and who have successfully completed requirements for the clinical/experiential education components of the curriculum. This form must be completed by the program faculty or the program coordinator.

Affiliated School Name: UMMC Unit/Department:
Affiliated Program Name: UMMC Campus Location:
Affiliated Program Coordinator: Rotation Start Date:
Affiliated Program Coordinator Phone: Rotation End Date:
Affiliated Program Coordinator Email: Type of Affiliated Student:




Please complete the information below for each affiliated student or affiliated
instructor who will be engaged at UMMC for the requested placement outlined above.



First Name: Middle
Initial:		 Last Name: External Email: Driver's License
Number:		 State That Issued
Driver's License:		 Passport Number
(If no driver's license):		 Cell Phone: Instructor/Student: Used Epic In
Last 12 Months?		 Meets Health
Requirements
Listed Below?		 Does student have
medical/religious
exemption for flu
vaccine documented
by affiliated program?		 Delete
Add Person


UMMC Health Requirements For Affiliated Students

    Affiliated programs must verify that affiliated students are compliant with UMMC TB screening and immunization requirements. Documentation must be maintained at the affiliated program for 2 years and provided to UMMC when audited in order to continue the affiliation. Affiliated students/instructors are encouraged to utilize the UMMC Affiliated Student Health Form.
  • Negative TB skin or blood test (or UMMC Affiliated Student Health Form B if previously positive) consistent with UMMC requirements consistent with UMMC requirements
  • Influenza vaccine during influenza season
  • 2 MMR vaccines (or positive measles, rubella and mumps titers)
  • 2 Varicella vaccines (or a positive titer)
  • Hepatitis B vaccine 3-dose series (or 2-dose Heplisav-B series after 11/2017 for ages 18 and older) or positive Hepatitis B surface antibody titer or UMMC declination statement. UMMC recommends Hepatitis B vaccine series and a positive antibody titer for optimal clinical safety.
  • Tdap vaccine (tetanus, diphtheria and acellular pertussis) within 10 years or Td booster within 10 years if prior dose of Tdap received after age 11 is greater than 10 years
  • Affiliated programs with influenza vaccine policies and accommodation review processes, must document the program's review and approval of the medical/religious accommodation and provide documentation to UMMC when audited. Affiliated students with program-approved medical/religious accommodations for influenza must wear N-95 masks (provided by the affiliated student or affiliated program) at all times while on UMMC campuses. Affiliated students from programs without influenza vaccine policies/accommodation review processes must be fully vaccinated to participate in the UMMC placement.



Attest And Submit
I agree to the following:
  • I am the Affiliated School Program Coordinator listed above and attest that all information provided on this form is accurate to the best of my knowledge. I attest that the documentation for all UMMC health/immunization requirements for each affiliated student listed above are kept on file at the affiliated school and program and will be provided to UMMC during future audits when requested.
  • I understand that this request for affiliated student placements is not considered approved until I receive confirmation from the UMMC affiliated student coordinator.
  • I understand that affiliated students must complete all onboarding requirements (UMMC orientation, compliance training, information security review, verification form, criminal review/badging, etc.) before beginning the rotation each semester. Failure to complete these procedures by the designated time will result in cancellation of the request for placement.
  • I acknowledge that affiliated students' learning experiences and access at UMMC expires on the end date identified above. A new request must be submitted each academic semester.
  • I understand that I must notify the UMMC affiliated student coordinator immediately when an affiliated student is withdrawn, dismissed, or unable to complete the learning experience for any reason.

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