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.

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.