Direct Referral Requirements to Complete:

Paperwork and Forms: Below is a list forms you must PRINT, read over, complete, sign and BRING with you to your scheduled Direct Referral Onboarding Appointment.

NOTE: Please do NOT drop off or email your application packet to our office unless specifically instructed in your "Direct Referral Approval" email. "Direct Referral Approval" emails are required to proceed to the STEP 2.

NOTE: Forms must NOT be older than 6 months of your Onboarding Appointment. If your forms are completed and signed more than 6 months ago, you will be asked to reschedule and recomplete them.  

1. Direct Referral Checklist: please fill out and bring the checlist to ensure that you have EVERYTHING COMPLETED BEFORE you attend an Onboarding Appointment. 
   • NOTE: Please do NOT attend an on-boarding appointment if you are missing anything. Email us if you have any questions: CRV@mednet.ucla.edu
   • Checklist for UCLA Students
   • Checklist for NON-UCLA Students (or Previous UCLA Students)
2. Direct Referral Coversheet and Acknowledgement
3. Direct Referral Volunteer Agreement
4. If you are a Current/Previous UCLA Employee, please complete: Employee-Volunteer Agreement Form
5. Abuse Reporting Signature forms (3 pages)
6. Patent Policy (Please read the policy, you will be completing the Patent Acknowledgement form in-person during your appointment)
7. Sexual Harrassment Information Sheet (Please read and keep for your reference)
8. Tdap Declination Form
9. Hepatitis B Declination Form
10. If you are under 18 years old, please complete: Minor Volunteer Forms

Training Certificates: In addition, you must complete the following training modules. You will need to generate a temporary ID to complete the online training modules (generate after first online training). Make note of the ID number after doing the first training as you will need to use the same ID for all six modules. Once you complete the online trainings, a certificate will be generated (HIPAA will generate a confidentiality form which you will need to sign and bring with you). Click Here for Step-by-Step Instructions. 

NOTE: Certificates must NOT be older than 6 months of your Onboarding Appointment. If they are older than 6months, we will request you to reschedule and redo the training.

PRINT the certificates and BRING them with you to your Onboarding Appointment:

1. HIPAA Privacy and Information Security Training
2. CICARE Annual On-Line Training
3. Safe Patient Handling Training
4. Volunteer Services Training
5. Radiation Safety: Radiation Hazard Awareness Training
6. Encryption Policy: Use of Mobile Devices and Removable Media Policy Attestation
   • If you are experiencing issues with opening any of the training modules, please try using the Internet Explorer browser.
   • If you are experiencing issues with completing any of the training modules, please do NOT pause or fast-forward any videos.
   • If you do not see your birth year when generating a TEMP ID, please use the most closest year available.  

Immunization/Health Clearance Requirements:

Please BRING the following Proof of Immunizations/Health Clearances (medical documentations) to the Onboarding Appointment. Below is a list of acceptable health documents:

• UCLA STUDENTS: Effective January 1, 2019: UCLA Students are required to BRING medical documentation (proof) of their:
  1. TB test results (see #1 below for more details) 
  2. Flu (Influenza) Vaccine (during Flu Season only, see #4 below for more details)
  3. AND provide a Health Clearance Letter from UCLA Student Health Ashe Center. (NOTE: You will be asked to reschedule if you are MISSING ANYTHING.)
     • Please read the instructions on how to obtain that letter: Instructions for completing UCLA Health – Volunteer/SRP Health Clearance Requirement
     • NOTE: Your Health Clearance Letter from UCLA Student Health Ashe Center should already include clearances for immunizations #2, 3, 5, and 6.
     • NOTE: If you do NOT have UCSHIP, virtually requesting this letter will NOT incur charges if you have ALL health clearance items uploaded (#1-6). 
• NON-UCLA STUDENTS: Please BRING your medical documents of the following immunizations and health screening test results (#1-4). Proof of #5-6 immunizations require forms that must be signed instead. 

Medical Documentation must:

• Be in the form of an OFFICIAL health/medical record, immunization record, printed/electronic version of a secure message from an official health record portal (i.e. Ashe Center, myUCLAHealth, etc.), or a copy of your lab results.
• Include your full legal name, your birthdate, and the provider/clinic information.
• NOTE: Please do NOT bring any doctor's note, hand written notes, hand written/printed letters NOT from a secure message from an official health IT portal, unofficial health/medical records, or illegible/untranslated documents.

Health Clearance Items: Please read over the requirements carefully as UCLA Health has very specific standards regarding health screenings/immunizations.

1. Tuberculosis (TB) Screening (Please read carefully)

If you have always tested NEGATIVE for TB, please provide: 

• Medical documentation of a QuantiFERON Gold (also known as t-spot) blood test completed within the last 3 months.
• (NOTE: EFFECTIVE September 1, 2018, TB SKIN TESTS WILL NO LONGER BE ACCEPTED AS PROOF OF TB CLEARANCE) If you are unable to obtain a TB blood test, then in order to accept the TB skin tests to complete TB requirement, you must provide all of the following:
  • Written reason or proof that the you are unable to obtain a TB blood test from the provider/insurance. 
  • Proof of TWO (2) NEGATIVE TB Skin Tests (one no older than 12 months, the other no older than 3 months).

If you have previously tested POSITIVE for TB via BLOOD TEST (NOT SKIN Test), please provide:

• Documented proof of a positive TB BLOOD TEST, (also known as QuantiFERON Gold or t-spot)(documentation of positive TB Blood Test from any date will be sufficient)

AND

• Medical documentation of a chest radiograph (chest x-ray) report indicating Negative TB results within the last 3 months.

2. Measles, Mumps, and Rubella (MMR)

• Medical documentation of TWO MMR vaccinations

OR

• Medical documentation of ONE BLOOD TITER indicating immunity (positive result) to MMR
• Disease history of MEASELS, MUMPS, and RUBELLA will NOT be accepted.

3. Varicella (Chickenpox)

• Medical documentation of TWO VARICELLA vaccinations

OR

• Medical documentation of ONE BLOOD TITER indicating immunity (positive result) to VARICELLA

• Disease history of CHICKENPOX will NOT be accepted.

4. Influenza Vaccine (Flu)

• Medical documentation of ONE Influenza (Flu) Vaccine administered AFTER August 1 of the calendar year. (Only required during Flu Season, effective November 1 to March/April.)
• Flu Vaccine Documentation is required for those attending On-Boarding Appointments between October 14, 2019 - April 30, 2020. 

5. Tetanus, Diphtheria, Pertussis Vaccine (Tdap)

• Signed Tdap Declination Form (please complete this form even if you are immunized)

6. Hepatitis B Vaccine (Hep B)

• Signed Hepatitis B Declination Form (please complete this form even if you are immunized)