Student Safety / Compliance / Privacy Pledge Form

Prior to your first clinical date at St. Anthony, please complete the Student Safety / Compliance / Privacy Pledge form below.

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All fields marked with * are required.

Student Signature and Attestation Page

First Name *

Last Name *

Email Address *

Expected Student Experience Start Date *

Expected End Date *

Safety and Privacy

I acknowledge that I have read and understand the information provided in the St. Anthony Student Orientation packet. I have asked my preceptor to clarify any questions. *

I recognize the importance of maintaining the confidentiality of patients and residents at St. Anthony Regional Hospital and Nursing Home, and of assuring their right to privacy. *

I, therefore, pledge that I will not divulge any information about a patient or resident with persons in or out of the hospital or nursing home facilities unless the other party has a professional need to know.

By typing your full name, you attest to the validation of your responses above:

Type First and Last Name *

Enter Today's Date *