Employee Exemption Form

Employee Exemption Form

For Current Jefferson-Lehigh Valley Employees ONLY - For Jefferson-Lehigh Valley Employees enrolled in an academic program affiliated with Lehigh Valley Health Network, part of Jefferson Health and will be completing clinical/non-clinical hours or a research/quality improvement project through Lehigh Valley Health Network, part of Jefferson Health, please complete this exemption form.
**This form is the the only documentation employees need in order to rotate at Jefferson-Lehigh Valley Region. Employees DO NOT need to complete health clearances or background checks. Employees, as a student, you must follow student/school policies and wear your school ID Badges. You are also strongly advised to check Jefferson ONE Academic Partners Page before enrolling in a school program to ensure that Jefferson-Lehigh Valley has an Agreement with your preferred school. Establishment of new affiliations is not guaranteed. If you are completing a research or quality improvement project for your academic program, please reach out to NORI for more information.**
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Social Security Number (last 4 onl*
SUI/Campus Key*
Personal Email: *
example@example.com
Phone Number*
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Emergency Contact*

First NameLast Name
Relationship to Student*
Emergency Contact Phone Number*
School/Affiliation*
Graduation Date*

MonthDayYear
Date
School Contact*

First NameLast Name
School Contact Phone Number*
School Contact Email*
example@example.com
School Experience Start Date at Jefferson-Lehigh Valley *

MonthDayYear
School Area(s) of Assignment/Experience*
Program/Course Name*
Name of Preceptor/Supervisor*
By signing this form, I declare that, as an employee of Jefferson-Lehigh Valley, I have supplied accurate and truthful information and I have completed my annual Core Curriculum.*

First NameMiddle NameLast Name
Date*

MonthDayYear
Should be Empty: