Student Verification Form

This form can only be completed by the program coordinator. This form indicates that you, the program coordinator, have the requirements listed below on file at the school (i.e., current background check, immunizations, etc.) for the student(s) listed below or on an attached list.

Student's Name Student's Name First Last
If you are filling this out for more than one student, please attach the list of your students below.
If you are submitting this form for several students, please attach the list of their names here.

Attach Files
School Coordinator School Coordinator First Last
School Coordinator's Email
School Name
School Program
Date Range
Background Verification Agreement

Background Verification Agreement By signing this form, the affiliated program verifies the student listed above or the attached list of students has current criminal background checks (no more than 12 months old), and that his or her record meets the Aultman Hospital permissible standards.
Verification of TB Documentation

Verification of TB Documentation By signing this form, the affiliated program verifies that the student listed above or the attached list of students have all Immunizations up to date, complete and on file at the institution. This agreement confirms that these health files comply with the standards set by Aultman Hospital and its accrediting body.
Verification of Immunization Records

Verification of Immunization Records By signing this form, the affiliated program verifies that the student listed above or the attached list of students have all Immunizations up to date, complete and on file at the institution. This agreement confirms that these health files comply with the standards set by Aultman Hospital and its accrediting body.
Verification of Influenza Vaccination Documentation

Verification of Influenza Vaccination Documentation Aultman requires students to receive an annual flu vaccine or wear a mask upon entry and complete a flu declination waiver. By signing this form, the affiliated program verifies that the student listed above, or the attached list of students have received the flu vaccination for the current flu season. This agreement confirms that these health files comply with the standards set by Aultman Hospital and its accrediting body.
Student Professional Liability Insurance

Student Professional Liability Insurance By signing this form, the affiliated program verifies the student listed above or on the attached list of students has current Professional Liability Insurance in the amounts set forth in the affiliation agreement.
COVID 19 Vaccination Documentation

This vaccination is required for all student experiences at Aultman. This requirement must be submitted directly from the student through their application.
Terms of Form

By signing below, the school representative agrees to produce any documentation indicated on this form as the school having on file within 1 hour of a request from Aultman for regulatory site visits. The school representative also agrees to random audits by Aultman so that Aultman can ensure the school is in compliance with Aultman standards. If an audit finds that the school is not in compliance with Aultman standards, the consequence could lead to cancellation of the student experience until Aultman standards are met.
*Only the program coordinator can sign this form*

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Student Verification Form

Student Verification Form

COVID 19 Vaccination Documentation This vaccination is required for all student experiences at Aultman. This requirement must be submitted directly from the student through their application.

Terms of Form

COVID 19 Vaccination Documentation

This vaccination is required for all student experiences at Aultman. This requirement must be submitted directly from the student through their application.