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FieldX Onboarding Form
School Name
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Program Tracks:
Please indicate what tracks you offer.
Comma separated
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Part 1: Data Imports
Student Roster Import:
Please upload a .CSV or Excel file of your active students.
Note: Must include First Name, Last Name, Student Email.
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Click to choose a file or drag here
Site Database Import:
Please upload a list of sites where you currently have active students or established contracts.
Note: Must include Site Name, Address, City, State, Zip.
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Click to choose a file or drag here
Part 2: Student Pre-Requisites
Mandatory Documents:
Which documents are required for "Pre-Application" clearance? (Check all that apply)
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Mandatory Documents: Which documents are required for "Pre-Application" clearance? (Check all that apply)
Professional Liability Insurance (Malpractice)
Criminal Background Check
HIPAA Training Certificate
HIPAA Questionnaire
State Counseling Board Student Permit
Program Code of Conduct Acknowledgement
TB Test / Immunization Records
Other (Please Specify)
Other Mandatory Documents:
Program specific documents:
Click to choose a file or drag here
Clearance Responsibility:
Who is responsible for clearing a student to begin?
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Clearance Responsibility: Who is responsible for clearing a student to begin?
The Clinical Coordinator
Automatic clearance once documents are uploaded
Part 3: Site Affiliation & Agreements
Established Sites:
Do you require a NEW Affiliation Agreement for every individual student?
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Established Sites: Do you require a NEW Affiliation Agreement for every individual student?
A
No: We use "Evergreen" or "Master" contracts.
B
Yes: We execute a specific contract for every single student placement.
Internal Documents:
When a student is placed at an existing site, do they need to sign any specific internal documents (e.g., Orientation Checklist)?
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Internal Documents: When a student is placed at an existing site, do they need to sign any specific internal documents (e.g., Orientation Checklist)?
A
No
B
Yes
Internal Document Upload:
If yes to the above, please upload the template here.
Click to choose a file or drag here
New Sites:
Do you require a formal Site Affiliation Agreement for new/non-established sites?
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New Sites: Do you require a formal Site Affiliation Agreement for new/non-established sites?
A
No
B
Yes
Template Preference:
If yes to the above, which template do you use?
Template Preference: If yes to the above, which template do you use?
We strictly use our University's standard agreement.
We are willing to review and sign the Site's own agreement.
We accept either.
Authorized Signatory:
Please provide the Name and Title of the authorized signatory for your program.
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Signatory Email:
Please provide the email address for the authorized signatory.
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Part 4: Supervisor Qualifications
Supervisor Data Points:
What information is required to approve a NEW supervisor? (Check all that apply)
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Supervisor Data Points: What information is required to approve a NEW supervisor? (Check all that apply)
Clinical License Number
State of Licensure
License Expiration Date
Years of Clinical Experience
Highest Degree Earned
Supervisor Documents:
What documents must be uploaded for a NEW supervisor? (Check all that apply)
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Supervisor Documents: What documents must be uploaded for a NEW supervisor? (Check all that apply)
Current CV / Resume
Copy of Clinical License
Supervisor Training Certificate
Supervisor Approval:
Who approves new supervisors in the system?
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Supervisor Approval: Who approves new supervisors in the system?
Field Experience Coordinator
Other: please specify
If other, please specify
Part 5: Field Experience Forms
Field Experience Forms:
Do you have any field experience specific forms to be incorporated into FieldX?
Ex: evaluation forms, supervision notes, MOUs etc.
*
Click to choose a file or drag here
Submit
