Southern Regional Medical Center


Faculty Information

  1. Review Clinical Information & Safety Manual
    • Sign page 118
  2. Review Student/Instructor Requirements for Info on Badges
  3. Read Instructor Information Page
  4. Complete Badge Request Form
    • Badge Type: Other
    • First & Last Name
    • Dept. Assigned to: Enter Assigned Unit
    • Length of Contract: Enter clinical start and end dates
    • Organization Name: WellStar School of Nursing
    • Contact: Lillian Valdez/ Administrative Associate I
    • Address: 1000 Chastain Road, Kennesaw GA, 30144 MD4102
    • Phone: 678-797-2890
  5. Read and Sign the SRHS Confidentiality and Nondisclosure Statement
    • Employee or Affiliate Signature: Sign Name and date
    • Employee or Affiliate Print Name: Print Name
    • Immediate Supervisor and date: Leave Blank
    • Employee or Affiliate SSN: Your Social Security Number
  6. Complete State and Federal Criminal Background Check and Ten Panel Drug Test
    • MUST BE WITHIN ONE YEAR OF CLINICAL
    • You will need to purchase another background check/drug test from Advantage Students if your background is older than one year
    • Release results to Southern Regional Health System
  7. Must have current AHA CPR card on file
  8. Must have current PPD Skin Test or Chest X-ray (if PPD positive)
    • PPD/ CHEST X-RAY MUST CURRENT WITHIN ONE YEAR
  9. Seasonal Flu Shot
    • Must be submitted before November 15th of each year.
    • Required November 15th through March 31st of each year

 

SUBMIT ALL FORMS TO Lillian Valdez IN ROOM 3004 OR

lvaldez2@KENNESAW.EDU