Fillable Premier Health job shadow application academic

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Premier Health job shadow application academic

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Job Shadow Application
Academic
Page 1 of 8 Job Shadow Packet Rev. 12/31/12 BRM, 02/26/13 LCG, 7/9/14 LCG, 2/9/15 YLM, 4/27/15 YLM, 8/17/15
YLM; 4/18/16 YLM; 10/19/17 YLM; 5/29/18; 12/4/18
JOB SHADOW INFORMATION
The Job Shadow Program is an observation only experience in a select department within Premier Health based on
availability. The participant will have an opportunity to observe and interact with a healthcare worker as they go about their
daily activities. Hands-on patient care isn’t part of the job shadow experience and will not be permitted. The purpose of the
job shadow experience is to foster an awareness of the skills required for a specific career and to experience healthcare
culture. This program was developed to assist college students meet observation experience requirements to gain
admittance into an academic program.
Note that the application process includes reviewing a separate document, “Premier Health: Job Shadow Rotation
Brochure” and Content Review. You will also need to complete the Content Review document. Failure to properly
complete the forms, return required documentation on time, and have a parent’s signature if under 18 years of
age, will result in a delay in processing your application.
GUIDELINES FOR JOB SHADOW
• Participants must fill out all required forms completely including: Job Shadow Application and the Waiver of Liability
and Health Form.
• It is required that you have the following:
• Influenza vaccine in the current season when participating in a job shadow experience from October 1
st
through
March 31
st
of each year.
• Proof of current two-step TB test, T-Spot, Quantiferon or chest x-ray is required
• Proof of MMR vaccination or immunization and Hepatitis B vaccination is required.
• The Waiver of Liability and Health Form is a legal document. The waiver form basically releases the Hospital from
liability if a participant is injured in any way. It is a promise not to sue the hospital for any injury and a promise to not
allow your health insurer to sue the hospital for payments made on your behalf. Fill out all the forms accurately and
honestly.
• Priority for job shadow will be given to those needing to obtain a job shadow experience as part of a college admission
process or to meet a college course requirement. Applications will be processed on a first come, first served basis.
• There is a 20-hour maximum job shadowing limit in many of the clinical areas.
Application Process
Please read the following instructions carefully. If you have any questions, please call Beth Marchant at (513) 974-4777 or
Yolanda Munguia at (937) 499-8805 and leave a message with a phone number where you can be reached or e-mail to
jobshadowing@PremierHealth.com.
1. Determine the facility, career interest you would like to job shadow.
2. Depending on patient/department needs as well as staff availability and the number of requests, we will try to
meet your job shadow request. If your request can’t be met, you will be contacted and offered an alternative if
one is available.
3. Fill out the application form completely. An incomplete application will place your request at the end of the
submission list. One application per participant.
4. Fill out the Waiver of Liability and Health Form. You will need to sign and have a parent or guardian sign if you
are under the age of 18.
5. Be sure to review the Premier Health Job Shadow Orientation Brochure and complete the Content Review
document.
6. Email the Application and Content Review documents to
jobshadowing@PremierHealth.com.
7. You will receive a phone call or e-mail regarding the time and location for your shadow experience.
All paperwork must be completed and turned by the submission deadline noted on the website. All
applications will be processed on a first come, first served basis. Job Shadow opportunities are limited.
You have a better opportunity of receiving your request if it is submitted as far in advance as possible.
Job Shadow Application
Academic
Page 3 of 8 Job Shadow Packet Rev. 12/31/12 BRM, 02/26/13 LCG, 7/9/14 LCG, 2/9/15 YLM, 4/27/15 YLM, 8/17/15
YLM; 4/18/16 YLM; 10/19/17 YLM; 5/29/18; 12/4/18
JOB SHADOW APPLICATION
Today's Date: __________________
Name: ______________________________________________ Age: _______________
Address: _________________________________________________________________
City: ______________________________ State: _______________ Zip: ____________
Telephone (with area code): __________________________________________________
Email address: ____________________________________________________________
Name of Parent/Guardian or Emergency Contact: _________________________________
Emergency Contact Phone Number: ___________________________________________
College/ Field of Study __________________________ Student Year _________________
Is this job shadow a requirement for a course or college application? Yes No
What are you hoping to learn or gain during this job shadow experience? ________________
__________________________________________________________________________
Please indicate your preference for job shadowing. If your facility choice and date are unavailable, an
alternative will be offered. Job shadow availability is filled on a “first come, first served” basis.
Facility Requested:
Atrium Medical Center Premier Health System Support
Upper Valley Medical Center Miami Valley Hospital North
Miami Valley Hospital Miami Valley Hospital South
Other (indicate location) ________________
Career interest you want to shadow:
Clinical
Dietetics/Nutrition Respiratory Therapy
Nursing Physical or Occupational Therapy
Patient Care Technician Pharmacy
Imaging Physician Assistant
Physician (student must contact and arrange with a physician for shadowing experience prior to completing
paperwork) Physician name and facility: _________________________________________________
Non-Clinical
Hospital administration Human Resources Sourcing/Materials Mgt.
Marketing/Communications Information Technology
Plant Operations/Facilities Environmental Services
Dates Available for Job Shadow:
1. __________________
2. __________________
3. __________________
Total Hours Requested: ________________ (20 hours maximum)
Job Shadow Application
Academic
Page 4 of 8 Job Shadow Packet Rev. 12/31/12 BRM, 02/26/13 LCG, 7/9/14 LCG, 2/9/15 YLM, 4/27/15 YLM, 8/17/15
YLM; 4/18/16 YLM; 10/19/17 YLM; 5/29/18; 12/4/18
JOB SHADOW WAIVER OF LIABILITY AND HEALTH FORM
PART ONE: WAIVER OF LIABILITY______________________________________________
For and in consideration of the participation of _______________________(name of participant) in
the Premier Health Job Shadow Program, I, for myself, my heirs, executors, administrators,
successors and assigns; do hereby release, acquit and forever discharge Premier Health, its agents,
employees, and all other persons who might be liable from any and all causes of action, claims and
demands of whatsoever nature and kind whether known or unknown arising from my participation in
said Program. Further, I, for my heirs, successors, administrators, executors and assigns do hereby
covenant not to bring any action against Premier Health, its agents, employees, and all other
persons, providing services in the Program and agree to indemnify and hold harmless the same in
the event any such action is hereafter brought, or claim is hereafter made.
It is further understood and agreed that I, for my heirs, successors, administrators, and assigns, do
hereby agree to indemnify and hold Premier Health, its agents, employees, and all other persons,
providing services in the Program with respect to any potential subrogation claims by any and all
third party payors with respect to payments made to the Hospital or any other health care or medical
providers for health care with respect to any injuries sustained in the course of my participation in
the Program.
This release contains the entire agreement between the parties hereto, and the terms of this release
are contractual and not a mere recital. I further state that I have carefully read the foregoing release
and know the contents hereof, and I sign my name as a free and voluntary act. I, the undersigned
student, do hereby acknowledge that I have read and understand the following statements.
I agree to abide by and be bound by the following statements in return for Premier Health allowing
me to participate in the Premier Health Job Shadow Program.
1. I will conduct my shadowing activities at Premier Health only under the supervision of a Premier
Health employee.
2. I will comply with all Premier Health rules and regulations, Premier Health policies and
procedures, Premier Health’s Behavior Standards and the Rules of Conduct outlined in this
application.
3. I understand that Premier Health retains the right to remove any student at any time.
4. I acknowledge that I am not an employee of Premier Health during the Program.
5. I understand that I am responsible for the cost of any medical care that I receive from Premier
Health for any reason.
6. I acknowledge my responsibility and liability regarding the confidential nature of all information
that I have access to at Premier Health by virtue of my participation in this Program.
7. I understand that I may not participate in the Job Shadow Program until I have read the
Orientation Brochure that includes, but is not limited to, confidentiality, fire safety, infection
control, and area specific requirements.
Participation in the Program is prohibited unless this Waiver is signed by the Student (and
Parent/Guardian if participant is under the age of 18).
________________________________ _______________________________
Participant’s Signature/Date Witness
________________________________ _______________________________
Parent/Guardian Signature/Date Witness
(If Participant is under age 18)
Job Shadow Application
Academic
Page 5 of 8 Job Shadow Packet Rev. 12/31/12 BRM, 02/26/13 LCG, 7/9/14 LCG, 2/9/15 YLM, 4/27/15 YLM, 8/17/15
YLM; 4/18/16 YLM; 10/19/17 YLM; 5/29/18; 12/4/18
PART TWO: HEALTH REQUIREMENTS
List the DATE and RESULTS of each test as well as providing proof of testing or results.
**Attach verification of each vaccination or immunization along with the Job Shadow
Application. Verification may be a receipt or immunization record.
Annual Influenza Vaccination* Date of Vaccination**: _______________________
Proof of Exemption if Applicable: ______________
*Only required if job shadow experience falls between October 1
st
and March 31
st
.
TB Skin Test
You must complete a T-Spot, two-step TB Test, Quantiferon or chest x-ray prior to your job shadow
experience. Note that the two-step TB test requires two separate skin injections. Allow up to 2 weeks
for the test to be completed.
T-Spot, Quantiferon or Chest x-ray
Date of Test: _______________________ Results:___________________
Two-Step TB Testing (Tuberculin Skin Testing/PPD) (Chest x-ray if history of +PPD)
Date of Test #1:_______________________ Results:_________________
Date of Test #2: _______________________Results:_________________
MMR
Rubella and Rubeola Titer (Documenting Immunity) or Documentation of 2 MMR Vaccines.
Date of Vaccine#1:_______________________
Date of Vaccine #2:_______________________
Hepatitis B
Date of 1
st
: _________ Date of 2
nd
: _________ Date of 3rd: _________
My signature below confirms that the above information is true, and that to the best of my knowledge
I am free of communicable diseases at the time of my observation/job shadow experience at
Premier Health. Participation in the Program is prohibited unless this Waiver is signed by the
Student (and Parent/Guardian if participant is under the age of 18).
______________________________
Participant’s Signature/Date
______________________________
Parent/Guardian Signature/Date
(If Participant is under age 18)
Job Shadow Application
Academic
Page 6 of 8 Job Shadow Packet Rev. 12/31/12 BRM, 02/26/13 LCG, 7/9/14 LCG, 2/9/15 YLM, 4/27/15 YLM, 8/17/15
YLM; 4/18/16 YLM; 10/19/17 YLM; 5/29/18; 12/4/18
ORIENTATION CHECKLIST
Review the information in the Orientation Brochure provided to you. When complete, initial each of
the boxes below. Doing so indicates that you read and understood the information presented.
ITEM OF REVIEW:
PARTICIPANT
INITIALS:
PARENT/GUARDIAN
INITIALS
(IF APPLICABLE):
Participant Responsibilities
Premier Health Mission, Vision, & Values
Patient Experience
Cell Phone Usage
Patient Rights
Emergency Numbers, Safety Codes, & Your Role
Infection Control – Hand Washing & Isolation
Infection Control – Biohazard Waste & Hazardous Spills
Infection Control – Protection Yourself & Exposure Info
Confidentiality/HIPAA Info (Information in form attached)
I agree that I have reviewed the information in the Orientation Brochure as indicated above by
my initials. I know that if anything comes up that was not covered within, I can go to my
preceptor, the manager of the department I am in, or to a member of the Learning Institute with
any questions/concerns.
Participant Signature:__________________________________ Initials:_______ Date:__________
Parent/Guardian Signature:_____________________________ Initials:_______ Date:__________
(if participant under the age of 18)
PART 4: CONTENT REVIEW:
1. Premier Health’s Core Values include:
a. Respect, Interest, Compassion, Excellence.
b. Responsibility, Interest, Compassion, Excellence.
c. Respect, Integrity, Compassion, Excellence.
d. Responsibility, Integrity, Compassion, Excellence.
2. Premier Health’s Patient Experience expectations:
a. Safety.
b. Quality.
c. Service.
d. All of the above.
3. Any patient information must be kept confidential.
a. True
b. False
4. Two important factors in response to a code or emergency at any Premier facility are what code is being
announced and location of the code.
a. True
b. False
5. I have reviewed and understand all of the content in the Premier Health Orientation Brochure. I will adhere to the
guidelines provided.
a. Yes, I will.
b. No, I will not
Job Shadow Application
Academic
Page 7 of 8 Job Shadow Packet Rev. 12/31/12 BRM, 02/26/13 LCG, 7/9/14 LCG, 2/9/15 YLM, 4/27/15 YLM, 8/17/15
YLM; 4/18/16 YLM; 10/19/17 YLM; 5/29/18; 12/4/18
STUDENT CONFIDENTIALITY STATEMENT
Security and confidentiality are matters of concern for all persons who have access to Premier Health data and
protected health information. Each person accessing Premier Health data and resources holds a position of trust
relative to this information and must recognize the responsibilities entrusted in preserving the security and
confidentiality of this information. Therefore, all persons who are authorized to access data and resources through all of
the Premier Health information systems, access protected health information in any form (electronic, written, verbal), or
through personal observation must read and comply with the confidentiality and security policies of Premier Health.
As a condition to receiving access to the information system(s), I agree to comply with the following terms:
_____ I will not access or request data on patients for whom I have no business or job related reason. In addition, I
will not access any other confidential information, including financial or protected health information, whether
written or electronic.
_____ I understand that the information access through the Premier Health system(s), medical records, or any other
method of recording patient information contains sensitive and confidential protected patient health
information, business, financial and employee information that should only be disclosed to those authorized to
receive it.
_____ I will respect the confidentiality of any protected health information, whether on computer, written, or oral, or
reports printed from the Premier Health system(s); and I will handle, store, or dispose of these records in
accordance with HIPAA regulations.
_____ I will not intentionally damage, corrupt, or inappropriately delete or destroy any data, protected health
information, or computer programs.
_____ I will comply with all policies and procedures and other rules of Premier Health relating to confidentiality of
information and login codes to the best of my ability.
_____ I will not serve as an Attorney in Fact or as Power of Attorney of healthcare for a patient and/or client of
Premier Health unless the patient and/or client are related to me by blood, marriage, or adoption.
It is the legal, moral, and ethical duty of Premier Health, its employees, students, and those who job shadow to
assure a patient’s privacy and hold in strictest confidence any and all information concerning the patient and his/her
family. No employee shall actively seek to obtain any information regarding patients’ illness beyond that which is
necessary to carry out assigned tasks.
I understand that my use of the Premier Health computer system(s) will be regularly monitored to ensure
compliance with the agreement. I further understand that if I violate any of the above terms, I may be subject to
disciplinary action, up to and including termination of contact or any other remedy available to Premier Health.
_____________________________________ __________________________________ _________
Name of Participant (typed or printed) Signature of Participant Date
_____________________________________ __________________________________ _________
Name of Parent/Guardian (if participant is under 18) Signature of Parent Guardian Date
Job Shadow Application
Academic
Page 8 of 8 Job Shadow Packet Rev. 12/31/12 BRM, 02/26/13 LCG, 7/9/14 LCG, 2/9/15 YLM, 4/27/15 YLM, 8/17/15
YLM; 4/18/16 YLM; 10/19/17 YLM; 5/29/18; 12/4/18
Job Shadow Behaviors and Questions for a Successful Experience:
• This will be an observation experience, no hands-on activities with patients are allowed.
• Be sure to eat a meal and have a glass of water or two prior to the shadow
• Act like this is a job interview.
• Arrive 10 minutes early.
• Dress appropriately and wear comfortable closed toe shoes.
• Leave your cell phone at home or in your car.
• Introduce yourself with a smile and a firm handshake.
• Act interested. Be enthusiastic. Ask questions. Be respectful and courteous.
• No gum chewing. Food and water can’t be brought to the job shadow.
• If you fall asleep, you will be asked to leave.
• The patient has the right to decline a student’s presence during care.
• Thank your professional at the end of the experience.
To get the most from your shadow experience, be prepared to be an active spectator. Take this
sheet and a clipboard along with you. When it is appropriate, ask questions and write down the
professional’s responses. Take time to write down your thoughts and impressions too. This is a
worksheet for you and does not need to be turned in.
• What kind of education and skills are needed for this job?
• Do you need a license for this job? If so, what does it take to get a license?
• What is the typical wage for this job?
• How and why did you get started in this job?
• Is this a typical day or is it sometimes different?
• How many hours do you work?
• What do you like the best and least about this job?
• Is continuing education required for this job?
• Does your professional have any advice for you?
• Lastly, a question for you to think about. Do you feel this is the job for you?
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Completed 3 February 2020

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