1) I have requested and my host institution hereby grants permission to be present in any setting sponsored by the Northeast Kentucky AHEC for observation to enhance my education.

In return, I, the Job Shadow Participant, agree to adhere to the following rules:
    a) Read any applicable job shadow program policy, and adhere to the policy. I will ask questions if I do not understand the policy;
    b) Will not be allowed direct patient contact;
    c) Will not be allowed access to the patient medical records;
    d) Will not receive academic credit for the experience;,
    e) Present this signed and completed application prior to the job shadowing experience (if a minor, a parent or legal guardian’s signature is mandatory);
    f) Follow good hand-washing techniques;
    g) Adhere to the job shadow dress code;
    h) Wear personal protective equipment if there is a potential of contacting blood or other body fluids;
    i) Wear a name tag identifying myself as a student;
    j) Inform my mentor/host facility staff if at any time I feel nauseous, dizzy or otherwise ill during the shadowing activity;
    k) Arrive promptly and remain flexible to allow for extenuating circumstances such as patient emergencies that might interrupt the schedule; and
    l) Remain at all times where directed and leave the areas when requested to do so by a physician, nurse, or administration;                                                                                    m) Inform my mentor of any potential conflict of interest I may encounter during the shadowing experience.

2) I understand the patient/resident’s right to confidentiality and agree to respect that right by not disclosing information regarding any patient or regarding the organization/administration.

3) I recognize that observing in the healthcare setting and any complication thereof may be emotionally distressing. I also recognize the primary responsibility of the physicians and personnel is to the patient; therefore, it may not be possible to provide immediate attention to me should the need arise.

4) Job shadowing opportunities may be terminated at any time at the discretion of the host facility, the Northeast AHEC or designee.

5) In consideration of the permission granted, I hereby release the physicians, the organization, and its staff members from any claims or liability, physical injury and/or damage including emotional distress or injury or mental anguish which may be sustained by me or the patient as a result of the presence of myself in any building sponsored by the host facility.

6) I am age 16 or older.

Attestation

I attest that I have read the information provided to me in the above orientation overview literature. I understand that I am responsible for the content in its entirety. Furthermore, while shadowing at St. Claire Regional Medical Center or any of its facilities, I will uphold the values and follow the guidelines for acceptable behavior as described in the orientation overview literature. By signing below, I acknowledge I have read and understand all information in the orientation overview. I understand that I can be dismissed from shadowing should it be determined that I did not follow the guidelines or policies defined in the overview. I acknowledge I can be asked to leave St. Claire Regional Medical Center immediately without cause. 

***Note: Parent/Legal Guardian signature required in addition to participant signature if participant is under the age of 18.***

St. Claire Regional Medical Center

222 Medical Circle, Morehead, KY 40351

Non-Disclosure Agreement

As a shadowing student, I understand I may come in contact with confidential medical or business information, both clinical and employee related, through written records, documents, ledgers, internal verbal correspondence and communications. I agree not to divulge or disclose to anyone other than those persons of St. Claire Regional Medical Center who are identified by written policy as having the "need to know" directly or indirectly, either during or after my shadowing experience, any confidential information acquired during the course of my experience. I understand and acknowledge that, in the event I breach any provisions of this agreement, St. Claire Regional Medical Center, in addition to any other legal remedies available to them, has the right to reprimand, suspend, and/or terminate my educational experience with or without notice at their discretion. By providing my digital signature below, I hereby agree to the conditions listed above.

***Note: Parent/Legal Guardian signature required in addition to participant signature if participant is under the age of 18.***

St. Claire Regional Medical Center

222 Medical Circle, Morehead, KY 40351

Badge Agreement

I agree to return the security badge, badge reel, and badge buddy which has been assigned to me for my use during my shadowing experience at St. Claire Regional Medical Center. I further agree to pay the cost of the badge in the event that I should lose or damage it. You may return badges to the AHEC office located on the second floor of the CHER building Monday thru Friday from 7:00 a.m. to 4:30 p.m. or we have a drop-off box outside of the AHEC Medical Library located on the 2nd floor of the main hospital. Please make sure these are returned when you leave or we will have to contact you/your program coordinator.

***Note: Parent/Legal Guardian signature required in addition to participant signature if participant is under the age of 18.***

St. Claire Regional Medical Center

222 Medical Circle, Morehead, KY 40351

Confidentiality Agreement

As a shadowing student, I understand that I will not be given access to phone systems, computer programs, or applications while shadowing and agree not to access these devices during my experience. I understand that, as a shadowing student at St. Claire Regional Medical Center, I may come in contact with information that is strictly confidential. I acknowledge this confidentiality and agree to maintain this information in strict confidence. I understand that confidential information includes but is not limited to patient information, quality assurance and utilization review information, strategic planning, hospital operations information and computer/phone/application password and codes information. I agree not to copy or reproduce any information I may come in contact with during my shadowing experience and beyond. I agree to comply with all St. Claire Regional Medcial Center policies regarding secuirty information. I agree to immediately report to the St. Claire Regional Medical Center Privacy Officer any unauthorized use, duplication, disclosure, and/or dissemination of confidential information by any person, including myself. I understand that violation of this agreement will result in loss of access to educational experiences. I understand that unauthorized release of confidential information may also have civial and/or criminal penalties as specified in the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the Health Information for Technology for Economic and Clinical Health (HITECH) Act, or other legislation. By signing this agreement, I agree that I have read and understand all information outlined in this policy. I agree to idemnify St. Claire Regional Medical Center fully for any and all damages, including legal fees that St. Claire Regional Medical Center may incur as a result of my intentional breach of this agreement. I agree that all obligations under this confidentiality agreement shall survive termination of my direct association with St. Claire Regional Medical Center, regardless of the reason for such termination.

***Note: Parent/Legal Guardian signature required in addition to participant signature if participant is under the age of 18.***