Xavier University's College of Nursing - Authorization to Release Records for Clinical Training

Sep 29, 2026

Uploaded by Hazel

Authorization form for students in Xavier University's College of Nursing to permit release of specified personal and medical-related records for clinical training. The form covers release of phone number, immunization and PPD records, results of criminal background check and drug screening, and documentation of HIPPA and OSHA education attendance to clinical-training institutions. It also allows release of additional records as requested by clinical sites, describes duration during enrollment, explains withdrawal by written notice, and warns that disclosed information may be subject to re-disclosure and reduced protection under federal regulations.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages2

Reading Time5 min

AccessFree to download

Clinical Training Record Authorization

Covered Records and Release Recipients

Duration, Withdrawal, and Disclosure Risks

Revised 8/2017 Xavier University's College of Nursing Authorization to Release Records for Clinical Training I am aware that the clinical rotations may require that Xavier University release my phone number, immunization and PPD records, the results of my criminal background check and drug screen, and documentation of my HIPPA and OSHA education attendance in order that I may participate in clinical training. I understand that if I do not meet the clinical requirements for the clinical sites set forth by Xavier University's College of Nursing, Xavier University's College of Nursing has the right to prevent me from attending the clinical site which may result in failure of the course associated with the practicum. Therefore, I authorize Xavier University College of Nursing to release my phone number, immunization and PPD records, background check􀃉 and drug screen results, and the records of my HIPPA and OSHA education to the institutions where I am scheduled for clinical training. I further authorize Xavier University to release other records as requested by the clinical site. This permission extends for the duration of my enrollment as a student at Xavier University's College of Nursing. I understand that I may withdraw this permission by notifying the Director of the College of Nursing program in writing. However, withdrawal of this authorization will not affect information that has already been released. I understand that withdrawing my permission may prevent my placement at outside clinical sites and prevent my completion of the College of Nursing program. I understand that the information disclosed pursuant to this authorization, may be subject to re-disclosure by the recipient institutions and may no longer be protected by federal regulations. Signature Date Printed Name Student ID \# (Banner) A Summary or Your Rlgbts Under the Fair Credit Reporting Act Th􀃃irfeevyoFeuedryperacoay yl FainsuourredlsrepoacnmpogeiAcyvect(Cfil(FCRAes b)RAManlau)isosptdesCRAstcyi-gntedareo creco pcrediuemtereaccapcyatgl,raathandi. and sandeHdpiovacyfonner burionessinnformaboesautYtiyooounucanie fichnd

FAQs

What records does Xavier University's College of Nursing request permission to release for clinical training?

The form authorizes release of the student's phone number, immunization and PPD records, criminal background check results, drug screen results, and records showing HIPPA and OSHA education attendance.

Can the authorization be expanded if the clinical site requests additional documents?

Yes. The student authorizes Xavier University to release other records as requested by the clinical site.

How can a student withdraw this authorization, and what happens after withdrawal?

Withdrawal is made by notifying the Director of the College of Nursing program in writing. Withdrawal will not affect information already released, and it may prevent placement at outside clinical sites and completion of the program.

Sep 29, 2026

Uploaded by Hazel