Please make note of the e-mail address and password used, as you will need it for future system use.
New User Details
Please enter your email address:
Please verify your email address:
MEDICAL STUDENT PLACEMENT APPLICATION
*Note: Virginia Mason Memorial requires medical student placement to be arranged/approved by the medical school PRIOR to the application process.
Please review the required items on the application prior to completing the form. The application does not offer the capability of saving and logging back into it.
There are several document links at the bottom of the document. Please ensure that you either have the capability to download the files to your computer or onto a jump drive, so you are able to review the documents while you take our online quiz. Once your application has been submitted, you will be automatically redirected to our Orientation Quiz.
Legal First Name
Estimated graduation date
Medical Student Type
DO - Osteopathic Medical Student
MD - Medical Student
PA - Physician Assistant Student
FNP - Family Nurse Practitioner Student
NNP - Neonatal Nurse Practitioner Student
ARNP - Advanced Registered Nurse Practitioner
CRNA - Certified Registered Nurse Anesthetist Student
CNM - Certified Nurse Midwife
NP-Nurse Practitioner Student
If 'other', please specify student type
Medical Student Year (while on rotation)
AT Still University of Health
Bellevue Community College
Brigham Young University
Central Washington Family Medicine
Central Washington University
Columbia Basin College
Des Moines University
Eastern Washington University
George Fox University
Idaho State University
Lake Washington Institute of Technology
Loma Linda University
Oregon Health & Science University
Oregon Institute of Technology
Pacific Northwest University of Health Sciences
Perry Technical Institute
PIMA Medical Institute
PIMA Medical Institute
Rocky Vista University
Skagit Regional Health
University of Arkansas
University of New England
University of Puget Sound
University of Southern California
University of Southern Indiana
University of the Sciences
University of Washington
Walla Walla University
Washington State University
Western Governor's University
Western Washington University
Whatcom Community College
Winston Salem State University
Yakima Valley Community College
Yakima Valley Technical Skills Center
If 'other', please specify school
School Contact Person
School Contact Person's Email
School Contact Person's Phone
Projected Start Date
Projected Placement End Date
In Case of Emergency, notify
Emergency Home phone
CRIMINAL HISTORY (RCW 10.97)
All information is required and failure to complete may affect results of inquiry and placement.
Have you been convicted of a felony or misdemeanor within the last 7 years?
If so, please explain
Alias/Maiden Name (s)
Date of Birth
Driver's License/ID Number
Health Requirements: Non-Employees (regardless of direct patient care) are required to meet the same health requirements as employees of Virginia Mason Memorial and its Affiliates. Health requirements are established in response to current Communicable Disease Center (CDC) for Healthcare Providers.
Two-Step Tuberculosis Skin Test (TST) - and annual TB test thereafter. Documentation of at least two separate TSTs with most recent TST within 12 months of beginning student rotation. Annual TST required. Students with a history of positive TST must have documentation of a negative chest x-ray, negative QuantiFeron gold, or documented completion of INH treatment for Tuberculosis. An annual surveillance form for signs and symptoms of active tuberculosis is also required for any students with a positive TST.
One QuantiFERON Gold TB Blood test may be accepted in place of the two separate TSTs.
Proof of Immunity to Measles, Mumps, Rubella, as evidenced by one of the following: Vaccine records that include two doses of MMR vaccine OR Laboratory testing that shows positive levels of antibodies of Measles, Mumps, and Rubella
Proof of Immunity to Varicella (Chickenpox)-Proof of immunity as evidenced by one of the following: Vaccine records that include two doses of varicella vaccine OR Laboratory testing that shows positive levels of antibodies for varicella OR Physician documentation of the disease
Tetanus, Diphtheria, Pertussis (Tdap, not DTP/DTaP) vaccine: Documentation that the Tdap vaccine has been received within the last 10 years.
Influenza vaccine- Vaccine will be required annually between November 1- May 1.
Hepatitis B Vaccine - Documentation of completion of the 3-dose Hepatitis B vaccine series or a positive hepatitis B surface antibody titer (HBSAB)
***VMM reserves the right to require other potential vaccinations as guided per recommendations of the CDC and adopted by the Infection Control Department.
ACCEPTABLE USE POLICY
Virginia Mason Memorial (VMM) is responsible for securing its computer systems, associated data, and communications network. In addition, VMM and affiliated agency employees are responsible for preventing the occurrence of inappropriate, unethical, or unlawful use of such systems and data.
General Principles, Guidelines, and Enforcement:
Please refer to slides 42-49 and the Appendix of the "Student Orientation" (link below)
Please refer to slides 50-58 and the Appendix of the "Student Orientation" (link below)
I understand that I may have access to protected health information (PHI) and confidential information about the business and financial interests (referred to as "Confidential Information" in this Agreement) of Virginia Mason Memorial (VMM). I understand that Confidential Information is protected in every form, such as written records and correspondence, oral communications, and computer programs and applications.
I agree to comply with all VMM policies and procedures to protect the confidentiality of Confidential Information. I agree not to use, copy, make notes regarding, remove, release, or disclose Confidential Information, unless it is permitted by VMM policy.
I agree not to share or release any authentication code or device, password, key card, or identification badge to any other person, and I agree not to use or release anyone else's authentication code or device, password, key card, or identification badge.
I agree to notify the appropriate manager immediately if I become aware that another person has access to my authentication code or device, password, key card, or identification badge, or otherwise has unauthorized access to the hospital's information system or records.
I agree that my obligations under this Agreement continue after my employment or my time as a student or volunteer ends.
I understand that breach of patient confidentiality may result in civil or criminal penalties under state or federal law.
STUDENT PLACEMENT ACKNOWLEDGEMENT
I understand and acknowledge that:
*My internship with Virginia Mason Memorial is voluntary and does not entitle me to wages, compensation or other fringe benefits
*I am being accepted into Virginia Mason Memorial's Internship Program as part of my studies and school and that I am required to participate as part of the class credit I will receive from school
*It is my responsibility to abide by all applicable policies and rules of VMM
*The training I will receive from VMM is for my own benefit and I am not entitled to a job at the conclusion of the internship period.
*I have received a copy of the Student Orientation and Environment of Care Roles & Responsibilities and will familiarize myself with the policies and procedures included
*I further agree not to disclose any confidential information concerning patients, research or other confidential information that I may learn in the course of my internship with Virginia Mason Memorial.
Please select each link below and download for reference regarding VMM, policies, safety, etc. The Student Orientation link will open the orientation training that will be used to complete your orientation quiz.
CLICK HERE to download the Environment of Care document
CLICK HERE to download our Student Orientation
***IMPORTANT--- This file will be used to complete your orientation quiz***
I grant permission to Virginia Mason Memorial and its affiliates to verify and obtain information on my employment, school records and license/certification. I hereby release my employers, schools, references, and any agencies contacted from any and all liability of damages for providing the information requested. Further, I certify that the above information is true and correct to the best of my knowledge. I also certify that I am in compliance with the required immunizations. I understand that misrepresentation or omission of facts is cause for rejection or termination of placement. Placement is contingent upon a satisfactory Criminal History Report. I understand that this application does not create a contract of employment or promise of future employment. I understand that my request for internship is voluntary, unpaid, and can be terminated at any time at the option of either the agency or myself.
My typed name below verifies that I have read and agree to comply with the above Confidentiality, HIPAA, Patient Rights, Code of Conduct, Environment of Care, Welcome Aboard Guide, and Acceptable Use Policy. I understand my responsibility in protecting these rights. My typed name below shall have the same force and effect as my written signature.
I agree to the above information is true and complete.
Please enter your name here:
Required: Please upload a head and shoulder photo with a plain background.
If you have any problems with the application process, please contact:
Student Experience Specialist
Have you ever worked for Memorial, VMM, or Memorial Physicans
When you submit your application, please wait for your photo to upload and you will be directed to complete the orientation quiz!