Fill - Free fillable Form 1.: Processing Instructions PDF form

Clinical & Non-Clinical Students

Processing Instructions

Please complete this electronic document to move forward with your on‐boarding

process. Remember to forward your completed packet to your Academic

Coordinator or UMC contact as instructed.

Associate Orientation Packet:

Make sure to read, complete and sign the forms below, submit to your school’s Program

Coordinator:

a. Associate Orientation Checklist:

b. Confidentiality Agreement:

c. Fair Employment Law

Acknowledgement:

d. Non‐Employee Security Agreement: handwrite or esign signature only/handwritten forms are not valid

e. Exhibit A – Clinical Student (only):

Background check:

Please verify with your school’s Program Coordinator if a new background check is required. If a new

background check is needed, go to http://www.precheck.com/students and complete a background

check. All submitted background checks must be less than a year old.

Required Documentation and Testing

a. Current 1-2-Step TB test or chest x-ray results (within the past 12 months)

b. Current 6-10 panel urine drug screen

c. Proof of immunization records (MMR, Hepatitis B, chicken pox, measles, mumps,varicella, and TDAP)

Current flu shot (during flu season) or declination

e. Current BLS (if applicable)

Contact your school’s Program Coordinator to coordinate completion of above items.

Associates Orientation

Complete the Associate Orientation Presentation and print the certificate that is generated at the

end, submit to your school coordinator. You may click the link above or the link listed on the web

page. The presentation should take approximately 1 hour and 15 minutes.

a. Complete presentation and print the certificate of completion, please include with your

Associates Orientation Packet submission to your school’s Program Coordinator.

b. If presentation is being completed as a class/group, the instructor should type the name of the

school, program and date viewing presentation (i.e. School Name – Nursing – 12/15/17).

Instructor should print the certificate and send with Letter of Attestation.

Proof of Insurance:

Please provide proof of medical insurance.

Submit the Packet to your school’s Program Coordinator

Once you have completed the above tasks, give the completed packet to your school’s Program

Coordinator. Each Program Coordinator must utilize the shared electronic folder system, in order to

prevent any email file size restrictions. After your completion of the necessary documentation, your

school’s Program Coordinator will instruct you on how to continue with the on-boarding process.

In absence of a school Program Coordinator, please contact UMC by calling Cindy

Hollingshed at (702)383-6239/Cindy.Hollingshed@umcsn.com or Leslie Connolly at

(702)207-8224/Leslie.Connolly@umcsn.com.(for Medical Students, Social Work, Dietary and HCA Interns

please contact Leslie).

Failure to submit a complete packet may cause delay in the start date of your rotation/internship.

Thank you for choosing UMC.

We are grateful and excited to have you on our team!

Parking Application and Map

Complete your student IPARQ profile to access a parking sticker for UMC. Students attending

UMC for less than a year will receive a temporary sticker in the UMC badge office, all others will

receive a sticker in the mail. Review the parking map and familiarize yourself with student

parking.

Corporate Compliance Handbook

Please read the Corporate Compliance Handbook as you will be held accountable for information

within it. The handbook is online and can be reviewed here.

ASSOCIATESORIENTATIONCHECKLIST

* Pleaseprintandsignthischecklistafteryouhavecompletedtheon‐lineAssociatesOrientationpresentation.

PrintName:________________________________________________Program___________________________

Checkoneofthefollowing:

SchoolName:___________________________________

Company

Name:_________________________________

Resident/Student/Instructor

Contractor/Vendor

Volunteer

InformationCovered:

PoliciesandProcedures

CodeofEthics,PatientsRelations,DressCode,HealthCareAdvancedDirectives,ExposurePreventionandExposureProtocol,

AbusePolicies,otherpoliciesthatmayapply

NationalPatientSafetyGoals

MandatoryEducation

HIPAA

EmergencyManagementandEmergencyPreparedness

CorporateCompliance

Fire/ElectricPowerSafety

ConfidentialityAgreement

ExposureProtocol/BloodBornePathogens

Diversity,CommunicationandTeambuilding

InfectionPrevention/SpecialIsolations

FairEmploymentLawReview

GeneralSafetyandHazardousMaterials

StrokeSignsandSymptoms

ThisistoverifythatIhavebeentrainedand/orreceivedtrainingmaterialsonthetopicslistedabove.Iamalso

responsibleforthetrainingandthematerialsdiscussedand/orhandedoutbyUMCduringthistraining.

SIGNATURE:_________ _______________________________________________Date________________________

Are you a current UMC employee?

Yes

2016 UMC Confidentiality Agreement Page 1 of 2

NAME: (PLEASE PRINT) _________________________________________________________________

DEPARTMENT or AFFILIATION: __________________________ TITLE: ____________________

During the course of your activity at the University Medical Center of Southern Nevada (UMC)

and its affiliates, you may have access to information which is confidential and/or proprietary.

This information may not be accessed, used, or disclosed except as permitted or required by

law and in accordance with UMC’s policies and procedures. In order for UMC to properly care

for patients, certain information must remain confidential. Improper access, use, or disclosure

of confidential and/or proprietary information can cause irreparable damage to UMC, its

patients and workforce members. Confidential and/or proprietary information that must be

safeguarded from improper access, use, or disclosure includes, but is not limited to:

1. Any personally identifiable information relating the past or present provision of

healthcare to an individual, eligibility of an individual for healthcare, or payment for the

provision of healthcare to an individual.

2. Medical and certain other personal information about employees.

3. Medical Staff records and committee proceedings.

4. Financial and statistical records, strategic plans, internal reports, contracts,

memorandums, peer review information, communications, computer programs,

technology, source code, third-party information, client or vendor information, etc.

5. Other information protected by regulatory or legal requirements.

I understand, acknowledge and agree that:

1. It is my responsibility to use confidential and/or proprietary information as minimally

necessary to perform my legitimate job duties at UMC.

2. I will not access any UMC electronic or other record relating to myself, any family

member, friend, or acquaintance unless I have a legitimate need to know for the

purposes of executing my assigned job duties at UMC, and only with written

permission from my manager.

3. It is not permitted for me to obtain copies of records for myself, or anyone else, without

submitting to the Health Information Management Department (HIMD) a valid

authorization or other sufficient legal documentation demonstrating my authority.

4. I will not access any UMC electronic or other record relating to a public figure

(including but not limited to entertainers, athletes, or prominent businesspersons, etc.)

unless I have a legitimate need to know for the purposes of executing my assigned job

duties at UMC.

5. If I am required to access non-UMC records or data to carry out my duties, I will not

access this information without a legitimate need to know for the purposes of executing

my assigned job duties at UMC.

6. I understand that moving or copying confidential and/or proprietary information from its

secure source requires written permission from the data owner. Examples would

include copying patient data to my workstation’s hard drive, email account, or a USB

storage drive. If approved, IT Security must be contacted to assist with securing the

movement of the information.

7. I am obligated to hold confidential and/or proprietary information in the strictest

confidence and not to disclose the information to any person or in any manner which is

inconsistent with applicable policies and procedures of UMC, or with state or federal

law.

2016 UMC Confidentiality Agreement Page 2 of 2

8. I am obligated to immediately report any known or potential inappropriate access, use

and/or disclosure of confidential and/or proprietary information to UMC in accordance

with UMC policies and procedures.

I am obligated to comply with safeguards designed to protec

t the privacy and security

of UMC’s confidential an

d/or proprietary information consistent with applicable policie

and procedu

res of UMC, and state and federal la

10.

I am obligated to ensure hard copies of confidential and/or pr

oprietary information are

securely sto

red in their designated location at all times, and are shredded or disposed

of in designated shredder container

s when no longer needed.

11.

I am obligated to ensure printed or electronic confidential and/or proprietary

information is never left unattended or exposed to unauthorized persons.

12. If I am issued a unique user code, it is my responsibility to maintain this code in a

confidential manner. This user code is my signature for accessing computer systems.

If I believe my unique user code is compremised I will immediately report that to UMC's

Information Security Officer.

13. My access and use of all hospital computer systems and other sources of confidentia

and/or proprietary information is

subject to routin

e, random, and undisclosed

surveillance by the hospital.

14.

Failure to comply with my confidentiality obligation may result in disciplina

ry action or

termination of my employment or affiliation with UMC in accordance with UMC’s

standard policies for workforce sanctions for privacy and security violations.

15. Impermissible access, use or disclosure of confidential and/or proprietary information

about a person may result in legal action being taken against me by or on behalf of

that person.

16. I understand that licensed health care providers are subject to sanctions for

impermissible access, use, or disclosure of confid

ential and/or

proprietary information,

including

license revocation, suspen

sion, probation and public reprimand.

17.

Any intellectual property or idea developed by me at the direction of UMC,

furtherance

of UMC business interests, and / or on UMC time,

or any intellectual

property or any idea derived there from, belongs exclusively to UMC.

18.

My confidentiality obligation shall continue indefinitely, including at all times after the

termination of my e

mployment or association with UMC and its affiliates.

I have read and understand this Confidentiality Agreement, have had my questions fully

addressed, and have had an opportunity to have a copy made for my permanent personal

records.

________

__________________________________________ ____________________

Signature Date

Fair Employment Law Review

Acknowledgement

I acknowledge that I have read and reviewed the information on the Fair

Employment Law Review. I also understand that I am required to observe

and abide by all rules, policies, procedures and standards associated with

fair employment laws as they pertain to my job duties and/or presence at

UMC, including any that may be given to me in writing or orally in the

future. I understand that while I am an employee, agent, or consultant of

UMC, or engaged by UMC in any other capacity, I may report any

suspected fair employment law violation to UMC’s Equal Opportunity

Program Manager. I am also aware that I may file a complaint at any time

with the Equal Employment Opportunity Commission or the Nevada Equal

Rights Commission.

My signature below confirms my acknowledgement and understanding of

the information contained in the Fair Employment Law Review.

_____________________________

Employee Name

(Print)

_______________________

School

__________________________________ __________________________

Employee Signature Date

IMPORTANT INFORMATION ABOUT THIS FORM:

 ALL FIELDS AT THE TOP OF THIS FORM ARE

MANDATORY AND MUST BE TYPED.

 HANDWRITTEN FORMS WILL NOT BE ACCEPTED.

 ALL SIGNATURES MUST BE DONE BY HAND

USI

NG UMC’S E-SIGN SERVICE.

NON-EMPLOYEE INFORMATION SECURITY

AGREEMENT

NMU00510 (06/06/18) Page 1 of 1

PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS

DATE OF REQUEST:

FIRST NAME: MIDDLE NAME: LAST NAME: TITLE:

COMPANY, ORGANIZATION or OFFICE: OFFICE PHONE: OFFICE FAX:

UMC DEPARTMENT: EMAIL ADDRESS:

CURRENT UMC WINDOWS ID:

 N/A

START / TRANSFER DATE: END DATE:

As a UMC User or Business Associate, as defined by HIPAA, I have read, understand and agree to adhere to HIPAA policies, procedures, and agreements that

pertain to Business Associates and other agents. I understand that my activity on the UMC Network will be logged / monitored and any unauthorized access or

unreasonable violation of the HIPAA “Minimum Necessary” rule will be cause for immediate revocation. I further understand and agree to the following:

SOFTWARE / HARDWARE:

1. I agree to use only authorized and secure electronic resources for UMC business purposes.

2. I agree not to install software, either UMC-owned or personally-owned, on any UMC asset without the express written permission of the Information

Security Officer or designee.

I agree not to install UMC software on personal devices (e.g. PCs, tablets, PDAs, etc.) without the express written permissi

on of the Information

Security Officer or designee.

4. I agree not to move UMC information from one location to another (either physically or logically) without the express written permission of the

Information Security Officer or designee.

5. I agree not to share UMC information with any other person (either physically or logically) without the express written permission of the Information

Security Officer or designee.

6. I agree not to install, attach, adjust or attempt to repair any UMC asset without the express written permission of the Information Security Officer or

designee.

7. Hardware (e.g. PCs, laptops, PDAs, USB storage devices or other removable media, etc.) is not allowed to be connected to the UMC Network

without the knowledge and/or express written permission of the Information Security Officer or designee.

SECURITY:

8. Protected Health Information (PHI) is to remain on authorized equipment and never moved to a personal or portable device or other media.

9. I agree not to give access to a workstation session or allow my login credentials to be used by any other person for any reason without the express

written permission of the Information Security Officer or designee.

10.

I agree not to adjust any user’s account or privileges without the express written permission of the Information Security Officer or de

signee.

11.

I agree not to create user accounts without the express written permission of the Information Security Officer or designee.

12. I agree not to adjust any system settings including (but not limited to):

Network settings b. Remote access settings c. System p

olicy settings d. Operating System settings (excluding desktop settings)

Application se

ttings other than

preferences (i.e. cannot modify intended access to data)

Note: Adjusting system settings requires the express written permission of the Information Security Officer or designee.

13. I agree not to allow any unauthorized individual to access any part of the UMC electronic information system or UMC information (either physically

or logically).

14. I agree not to attempt to access systems or services unless I have formal and approved documented access to the systems or services.

15. I agree to maintain confidentiality of all information in all forms (e.g. paper, electronic or other) and will provide UMC with information about our

security practices upon request.

16. I agree to return, securely delete or destroy all confidential data acquired from UMC when that data is no longer required.

17. I agree to electronically transport information to and from UMC only when approved in writing by the data owner using UMC predefined secure

methods.

► UNAUTHORIZED MODIFICATION OR ALTERATION OF THIS DOCUMENT WILL RENDER IT NULL & VOID AND WILL TERMINATE THE

ACCESS REQUEST PROCESS.

► IN THE EVENT THAT ANY OF THE ABOVE POLICIES ARE VIOLATED OR THIS FORM IS FOUND TO HAVE BEEN ALTERED WITHOUT

AUTHORIZATION, THE REQUESTER WILL BE PENALIZED IN ACCORDANCE WITH UMC POLICY REGARDLESS OF SIGNATURE ON THE

ALTERED FORM.

*Requester’s Signature: Date:

*Managing Representative’s Signature: Date:

Department Head’s Signature: Date:

*(Note: The term “Requester” is defined as a formally authorized non-employee performing or facilitating services for UMC and

the term “Managing Representative” is defined as the Project Lead or Site Manager from the Requester’s organization.)

Student/Instructor Clinical Affiliation Agreement

Exhibit A

WHEREAS, I am a student at ______________________________________________

(hereinafter “SCHOOL”);

WHEREAS, SCHOOL and University Medical Center of Southern Nevada (hereinafter

“HOSPITAL”) have entered into a Clinical Affiliation Agreement (hereinafter “AGREEMENT”) to

provide students of SCHOOL with clinical experience and training; and

WHEREAS, I desire to take part in said Clinical Education Program (hereinafter

“Program”).

NOW, THEREFORE, I stipulate and agree as follows:

1. I have received and reviewed the HOSPITAL’s orientation materials and the

written regulations which will govern my activities while at the HOSPITAL.

2. I agree to follow the HOSPITAL’s administrative policies, standards, and practices

in effect while I am a student/instructor at HOSPITAL.

3. I agree to follow HOSPTIAL’s Health Insurance Portability and Accountability Act

(“HIPAA”) policies and procedures.

4. I agree to comply with all federal, state, and locals laws and/or regulations

relative to my activities at HOSPITAL.

5. I agree that all patient records and all HOSPITAL statistical, financial,

confidential, and/or personal data received, stored or viewed by me shall be kept in strictest

confidence by me.

6. I understand that before I may be admitted to the Program to be conducted at

HOSPITAL, I must:

a. Provide evidence of appropriate health insurance,

b. Undergo a physical examination demonstrating my ability to perform the

essential functions of the job (with or without reasonable

accommodations),

c. Take and pass a pre-placement drug screen,

d. Submit to two-step TB Skin Testing

e. Demonstrate exposure to or vaccination against Rubella, Rubeola and

Varicella, and

f. Demonstrate vaccination against Hepatitis B or exercise of refusal to be

vaccinated.

g. Provide HOSPITAL with access to my background check results.

7. I understand that before I may commence training or activities at HOSPITAL, I

must complete HOSPITAL’s orientation Program designed to familiarize students/instructor

with their responsibilities and with their work environment.

8. I understand that my student/instructor identification badge must be worn at all

times and be clearly visible. Badges may not be worn backwards and should be displayed at

chest level or higher.

9. I acknowledge that I am responsible for providing the necessary and appropriate

uniform and supplies required but not provided by HOSPITAL and for securing living

accommodations and transportation.

10. I acknowledge that I will not be an employee of HOSPITAL while engaging in the

Program at HOSPITAL and that I am ineligible to receive any benefits from HOSPITAL including,

but not limited to, industrial insurance coverage.

______________________________________ _____________________

Student’s/Instructor’s Signature Date

______________________________________

Student’s/Instructor’s Printed Name

_____________________________________

Program of Study

New Student Parking Location

Students must park behind the Lied Ambulatory building on Pinto Lane or at Charleston and

Ranc

ho in the parking lot by the TLC Women's Center.

The parking lot is behind the Lied Ambulatory building on the north side. Students

should go east

on Pinto Lane, take the left driveway after the Clark County Social Services building then continue

around to the rear parking lots. It is a lighted area, well labeled as UMC parking. There is a shuttle to

take students

to the hospital.

For your safety and security, UMC’s Public Safety encourages students to utilize the shuttle services

to and from the main campus.

Students scheduled for night shift clinical rotation do not have to park in the remote lot;

park in the parking deck next to the Emergency Dept.

Call for shuttle pick-up at 702-383-1810

All current students will be required to register online via the new IParq system to obtain a new

parking permit and to be able to continue to park on campus.

What do you need to do?

To register, please go to https://umcsn.thepermitstore.com/purchase.php

Students will need to input their last name and school affiliation to access parking permit

requests.

Who do I contact for more information or support?

Please contact Public Safety with any questions at 702-383-2286.

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