Cobb County Community Service Board

Cobb County:

Ready to Work

Hartmann Center
Ready to Work Program
Mothers Making A Change
Cobb Crisis Stabilization

Cobb Recover Center
Dual Diagnosis



  1. Read the Handbook
  2. Intern Acknowledgement
    • Your signature and Date
  3. Intern Application

    • 1st Page
    • Name:  Print your name
    • Date: Todays date and day time phone number
    • Dates for placement/internship & Days and time available for placement/internship: begin and end date will be entered for you.
    • School, College, Institution: Kennesaw State University
    • Degree of Certification Desired: BSN   Major: Nursing
    • Program Course for which placement/internship is required: 3314
    • Projected Graduation Date: Semester and Year of graduation
    • Answer questions 1-3
    • Don’t complete #4 or #5

      2nd Page
    • Don’t complete this page, but submit with your paperwork
  4. Intern Policy Signature Sheet  
    • Complete entire form
    • Initial number 1-10
  5. Confidentiality & Technology for Interns – submit only page 2
    • Employee/Volunteer/Intern/Signature: your signature and todays date
    • Print Full Nam: Print your name
    • Witness Signature : Have your family of friend to be your witness and date
  6. Release for information – This forms must be fully completed or you will not be able to start clinical
    • Print clearly filing in ALL information
    • MUST INCLUDE:  SSN & Daytime phone#
    • E-mail:  KSU E-mail address
    • Signature of Applicant/Employee Your signature and date
  7. Drug Free Work Place
    • Print and  sign your name
  8. Read the HIPAA Presentation and Complete HIPAA for Intern Test
    • Complete and submit
  9. Read the Infection Control Orientation Packet and Complete the Infection Control Orientation Quiz and submit
    • Complete and submit
  10. Check your Infection Control Orientation Quiz & Acknowledgement
  11. Infection Control Signature
    • Employee/Volunteer/Intern/Contractor Signature:  Your signature and date
  12. Person-Center Ed Services  
  13. Your clinical instructor will contact you to schedule an appointment for drug testing and to complete the necessary paper work for Human Resources

Medical Documents that must be submitted with your clinical paperwork


  1. Current PPD within 1year or chest x-ray report
    • You must take to your appointment:
      • Social Security Card (passport or birth certificate if student does not have SS card)
      • Driver's License
    • Go to and read the information on these policies:  4081 Equal employment & Unlawful Conduct, 4089 Standards of Conduct Policy, 4079 Cultural Competency And Diversity Plan, 4053 Sexual Harassment Policy, 4088 Workplace Violent Prevention Policy, 3004 No Smoking Policy, Drug-Free Workplace.  After you have read the following policies including the attached Person Centered Services Page and completed the intern application, sign the Policy signature sheet.


Document Checklist


Intern Acknowledgment

Intern Application  (2pages)

Intern Policy Signature Sheet

Confidentiality and Technology for Interns

Release for information

Drug Free Work Place


Infection Control Orientation Quiz & Acknowledgement

Current PPD or Chest X-ray