Clinical Affiliation Application

Please complete the Intern Information/Student Affiliate Form.
All student affiliates must be fingerprinted for the Department of Developmental Disabilities (DDD) and the Department of Education (DOE) by Morpho Trust.
1. 2022-DOE DDD Fingerprinting Instructions for New Applicants
2. DHS Universal Fingerprint Form (2) (for DDD fingerprinting)
3. NEW Background check_Appendix A
Morpho Trust requires separate appointments for each agency, but you must schedule both of the appointments during one visit.
All original paperwork, including copies of the two receipts received from MorphoTrust, should be sent to Human Resources prior to your program start date.
Upon acceptance into the Clinical Affiliation program, all student affiliates must provide a recent (within one year) physical exam performed by a licensed physician, nurse practitioner, or physician assistant indicating freedom from communicable disease and ability to perform the physical demands of the position.
All student affiliates must provide proof of a TB blood test (IGRA) or 2-step Tuberculin skin test within the past year – Chest X-ray if positive tuberculin responder (must submit past result and x-ray).
All student affiliates must provide a copy of immunization records which indicate receipt of MMR vaccine (2 doses) in childhood and the completed Hepatitis B vaccine (3 doses) or immune titers.
All student affiliates must provide proof of a Tdap vaccine – One dose as an adult.
All student affiliates must provide proof of COVID-19 vaccination – Primary series plus booster.
All student affiliates must provide proof of proof of varicella vaccination or titer.
All health information (#5, 6, 7, 8, 9 & 10) should be submitted to Employee Health on the day of your arrival at Matheny or faxed in advance to the confidential fax #: 908-781-6816, addressed to Joan Ray, Employee Health Coordinator.
Please complete the following forms and email Vanessa Vitez at vvitez@matheny.org or fax (908-781-6816) prior to your start date: Background Check Authorization
1. NEW Background check_Appendix A
2. Central Registry Form
Prior to the commencement of your clinical affiliation, your University/College must provide Matheny with a Certificate of Insurance.