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.
Effective July 1, 2026 employees DO NOT need to complete health clearances or background checks, however, employees will need to be enrolled into LVHN's scheduling system, InPlace. Currently, there is a $45.00 subscription fee to utilize InPlace, good for one year.

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.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
SUI/Campus Key
Personal Email:
example@example.com
Phone Number
Format: (000) 000-0000.
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
Format: (000) 000-0000.
School/Affiliation
Graduation Date

MonthDayYear
Date
School Contact

First NameLast Name
School Contact Phone Number
Format: (000) 000-0000.
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: