Educational Experiences for Advanced Practice Provider Students

Students will need to complete ALL of the required paperwork listed below and save each requirement as a separate PDF/JPEG file. (If there are multiple pages in the requirement, please be sure to save all pages of the requirement in one file.) Students should title the saved documents according to their name. UPMC Employees are still required to submit all paperwork — we do not have access to UPMC HR files.

These documents will need to be uploaded onto our online application website.

All forms must be hand-signed; electronic signatures will not be accepted.

• Official documentation (a certificate or letter from the training agency) stating that you’ve completed approved training in child abuse recognition and reporting requirements. Go to a free online training course here.
• Note from your health care provider on office letterhead or a prescription that indicates that you have been seen within the year and are physically fit for clinical rotations
• Results of a tuberculin skin test (Quantiferon Gold, T-spot test or PPD - must not be more than one year old) or chest x-ray (must not be more than three years old)
• Hepatitis B titer or proof of immunization
• Rubella titer or proof of immunization
• Proof of Tdap immunization within the last 10 years
• History of varicella (proof of disease, copy of your titer or proof of immunization)
• Evidence of Flu Vaccination (only required for students requesting a rotation during the time period of August-March). Please reach out to the OAPP at APPstudents@upmc.edu if you would like to request an exemption form.
• Certificate of liability insurance (you will need to request this information from your program)
• UPMC Student/Visitor Confidentiality Agreement (PDF)
• Signed last page of UPP Handbook (PDF)
• Signed HIPAA Compliance Form (PDF)
• Student Agreement, Exhibit A for IMS Codes (PDF)

Pennsylvania State Clearances - All clearances must have been obtained within the last five years.

• Act 33 clearance (Pennsylvania Department of Public Welfare Childline Clearance)
• Act 34 clearance (Pennsylvania State Criminal History Record)
• Act 73 clearance (Federal Criminal Background Check); When applying for this clearance, be sure to process your request through The Department of Public Welfare, not the Department of Education.

New York State Clearances - All clearances must have been obtained within the last five years.

Students will need to be cleared through the NY Justice Center and Child Abuse Registry. To start the process the following forms must be filled out and emailed to UPMC Chautauqua Administration/Linda Sampson at sampsonls@upmc.edu:

• Code of Conduct for Custodians of People with Special Needs (PDF)
• Justice Center Staff Exclusion List SEL Check Form (PDF)
• NYS Protection of People with Special Needs Act Notice to Mandated Reporters/Receipt (PDF)
• Statewide Central Register Database Check/LDSS Child Abuse form (PDF)

Once you have been cleared, Linda will send you confirmation of your clearances that will need to be uploaded as a part of your application. For current UPMC employees in the state of NY, UPMC Chautauqua Human Resources can provide copies of the clearances if they have been scanned to your personnel file. There will not be a child abuse form for anyone hired after integration (6/25/2017). If the forms are not available, you will need to complete the process following the directions above.

Mandatory Modules

• Bloodborne Pathogens
• Compliance and Ethics Review
• Creating an Inclusive Workplace
• Emergency Preparedness
• EMTALA: Emergency Medical Treatment and Labor Act
• Environment of Care
• Harrassment-Free Workplace
• Infection Prevention
• Patient Safety
• Privacy and Information Security Policy Awareness 
• Stroke Awareness
• Understanding the Elder Justice Act
• Understanding Infant Security
• Age Related-Care and Abuse
• Clinical Support – Restraints Training