New Student Orientation Paperwork

Please provide the name, relationship, and phone number of your emergency contact.

My signature below acknowledges that I have received, read, and understand the Criminal Background Check Policy as it relates to the Arkansas Nurse Practice Act, ACA Section 17-87-312 and Licensing Restrictions Based on Criminal Records Act, ACA Section 17-3-102. I also understand that admission to the UA Little Rock School of Nursing does not guarantee being eligible to sit for the National Licensure Examination-RN (NCLEX-RN).

As a participant in simulation-based learning experiences, I understand the significance of confidentiality with respect to any patient or participant information (electronic, written, overheard, or observed) in the simulation setting. The term patient or participant is extended to anyone appearing in the Center for Simulation Innovation (CSI) setting including, but not limited to: - paid actors - enrolled students - nursing students - students from other UA Little Rock programs of study - external organizations - virtual or augmented reality - any human patient simulator (manikin) I will hold privacy and confidentiality of patients and participants in the highest regard, consistent with the Health Insurance Portability and Accountability Act (HIPAA), and as required by the Family Educational Rights and Privacy Act (FERPA). Any supplies provided in CSI are not to be used on living people and should be used only on manikins or task trainers. Simulation supplies are not actually sterile and may be expired or otherwise not safe for use. Further, I agree to report any violation of confidentiality that I become aware of to my faculty facilitator, course coordinator, or CSI director. I understand that failure to maintain privacy and confidentiality can result in being referred to the University of Arkansas at Little Rock School of Nursing’s Professional Conduct Council (PCC) for potential sanctions as outlined in the PCC policy.

Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to UA Little Rock School of Nursing Center for Simulation Innovation, its affiliates and agents, to use my image and likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet). This consent includes, but is not limited to: (a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or recording of my voice; (b) Permission to use my name; and (c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings for educational and awareness. This consent is given in perpetuity, and does not require prior approval by me.

After submitting this form, you will receive a follow-up email at your UA Little Rock email address. This will contain a copy of these documents for your record and will serve as a reminder of the orientation date you will be attending.