1 Start 2 Complete This document is for use by an authorized BSWH-affiliated school official/personnel to attest their compliance with the affiliation agreement allowing students and/or faculty to participate in clinical rotations at BSWH. This form is to attest that all faculty and students listed within have met the requirements marked below for participation in the referenced education program. For questions, please email BSWHeduattestations@BSWHealth.org. School: * City: * State: * Program Type: * Allied Health Nursing Medical School Other... Program Type: Other... Name of clinical rotation (e.g., program name). * Do not use acronyms or abbreviations (for example physical Therapy not PT.) Anesthesiologist assistant Athletic training Audiology Biomedical engineering Business Administration Cardiac rehabilitation Child Life Diagnostic medical sonography Dietary Dosimetry Echocardiography Emergency medical services/technician Exercise/sports science Genetic counseling Healthcare administration Health, human performance, and recreation Health information management Histology Instrument Processing Kinesiology Licensed professional counseling Limited medical radiologic technology Magnetic resonance imaging Mammography technician Medical laboratory science Medical laboratory technician Molecular pathology Nuclear medicine Occupational therapy Paramedic Pathology assistant Perfusion Pharmacy technician PharmD Phlebotomy technician Physical therapy Physician assistant Public health Radiation therapy Radiology Recreation therapy Respiratory therapy Social work Speech-language pathology Surgical first assistant Surgical technology School program coordinator/liaison: * BSWH Location: * Waco Temple College Station/Brenham Austin Region (includes Austin, Round Rock, Marble Falls, Lakeway, Buda, Cedar Park, Pflugerville, Taylor) Program Start Date: * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year202320242025 Program End Date: * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year202320242025 Vaccines Required for all Programs * Select all that apply. Influenza vaccine - Documented vaccination within the then-current flu season Is Exempt from receiving the Influenza vaccine per our school's vaccine exemption process. Met COVID-19 vaccine policy requirement Is Exempt from receiving the COVID-19 vaccine per our school's vaccine exemption process. TB skin test - 2-step TST or by Q-Gold or T-Spot blood assay, or another testing method acceptable to BSWH Additional Vaccines required for programs involving direct patient care or interaction * Select all that apply. Hepatitis B series - Documentation of 3 doses or a positive titer MMR (measles, mumps, and rubella) - Documentation of 2 doses or a positive titer Varicella - Documentation of 2 doses or a positive titer Tdap (tetanus, diphtheria, and pertussis) - Documented vaccination within 10 years before the first day of the applicable rotation period Is Exempt from receiving the below listed vaccine(s) per our school's vaccine exemption process. If you select this option, you must also select "Other" and list the vaccines the student(s) is exempt from receiving Other... Additional Vaccines required for programs involving direct patient care or interaction Other... Other Attestation: * Select all that apply. Standard BSWH orientation packet with certificate of completion submitted to the school Applicable didactic prerequisites for the clinical rotation Current BLS for Healthcare Provider - if a precondition and ongoing condition for program participation Criminal background check - Trainees have been subject to a background check in accordance with the School's Background Check protocol where the background check returns with no criminal activity and no other activity adverse to participation in any program Drug screen - Trainees have been screened for the presence of controlled substances in accordance with the School's Drug Screening Protocol where the screening detects no controlled substance List all students and faculty below that have met the above checked compliance requirements. Please complete an additional attestation if more than 50 students. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 School Attestation: * By entering your name in the blank you are attesting the above information is correct and true and you are authorized to certify the information on behalf of the school. Title: * Title of person authorized to attest. Date of Attestation: * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year202320242025 Leave this field blank
