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    Fabio Vanuzzi
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    Intermountain student packet

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    Intermountain Student packet

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    Intermountain student packet

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    42 views13 pages

    Intermountain Student Packet

    Uploaded by

    Fabio Vanuzzi
    Intermountain student packet

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    of 13
    Extended Student Observational Experience ‘complete the following forms and return to your assigned Student Programs Coordinator. Student Profile E, Medical Incident & Disease Exposure Release of Lisbility Pro-requisite Testing Attestation F. Student Orientation Quiz gatiality Agreement -G, Required Immunizations detine Student Profile / Identification Incomplete packets will be returned | Black oc Ain Ainerean [atptspanic or Latin {1 Native Hasan or Other Pasi Ilander (‘Gwnite (1 Two ar More Races DINot Disclosed ‘employed by Intermountain Health? Ye YiNo frowy aT 23 - Aye 103/08 ZY ‘observation at Intermountain facility listed: his profile, you will be provided a student ID badge. ID badges mustbe returned atthe end lexperience or each semester if your experience extends over several wesks, Please check ‘Coordinator for ID badge retrieval instructions. of Intermountain, your employee ID badge must not be wor while you are (cs noted in this packet) by the CDC: Medical Exemption C/Religious Exemption ‘exemption approved by school: (mm/ddyypy) ‘The folloping information i w ‘The Centers for Disease Con sates of healthcare pers reporting this information a Tegore not to disclose information. DNovavax Unknown, OB) oe | Be DModtma ONovavax Pfizer OM Unknown AAR 21 a Unknown (rmnldetyyy): ON | 22-/_ DY Revie 112023, Intermountain Health Pre-requisite Testing Attestation luntary. If you choose not o disclose, please indicate below. ‘and Prevention (CDC) require hospital 0 continue reporting COVID-19 vaccination rl. Your responses are voluntary but help Intermountain fulfill the CDC's requirement in 1 Johnson & Johnson (no longer available) Date unknown (2424 | 20 1D Johnson & Johnson (no longer available) ON 11 Date uninow, Talis opp Nonuee ‘Student Name (pri & [r»A—_— oalor] zy Date B vd sand yountain INTERNOUNTAIN HEALTH ‘ACCESS AND CONFIDENTIALITY AGREEMENT | SECTION 1.0. PURPOSE AND DEFINITION 1.1. Pupse ofthis Agreement. Faceral and state avs, s wala iiormounn Hkh (termounsin) poles, protect Condon Information, assure bet temas crfidets, and perils be use for aproprate puposes. Those laws and polls assure tat Infomaton, wich sestve and valuable, remains confdensl. Thay also pera yu use Conf Infomation ony ‘25 oossary to cccompish ine and approved purpazes. You may need acose to Coxiental Iran because you have one of te fatowng roles: a mombor os dined by he Heath hauzance Potsbiy end Accourtablty Ac (HIPAA), which Member oF ot ltemcuran created Provider (a Provide 0t eat Sencas, ne. (2 "Veror or Agent: or uh use inocu reoureos andor hee eecess to iermouian inomeaton (Resource ‘means data propretary fo niermounkin, ober companies, or her persons, plus any cher and which Intermountain has a duty o protect You may iaam cr acsess Corfdontal formation the folowng iformason ft mairtaned by, or obtanad fro, Infernounta: pho, employment (excep that this does rot prevent individuals from dscussing fetes and condtions of employment), or heath information (neudng Protected Heal iformaton); | Peor-reviw infer 'ntermountat's business infomation, (¢.9, francial and stats records, svalegc plans, intemal repos, memos, contra, communicators, opty compubr progr, sae coe, proprtary lociobgy to} and 1) lntermounta's rati-prtys inormatin (comput progam, dent end veror propery domaton, source cx, || ropa technclogy, te). SECTION 20. YOUR DUTIES UNDER THIS AGREEMENT pal Duties. To quay to pesess or use ConidentalIfornaton, you wil comply wit the laws and informcuntsin pices goveing finial Iriomaton. Your pnp cutes regarding Confidential ronmaton ince, butare nt ited to, he allowing: ‘A. Setequard the privacy and securty of Cotidontaliniomatio; Uso Centr Inometon ony 2 nead pom yogis and trmoutsn approved responses This means ©) among oer tings, tat youl nt || @) Dug, copy, felease, sol, oan, revise, ler, of desiroy any Content information except as propoty authorized fer etre nd hierar rotpnsbiis: any Intermountain usemame and password, access codes, ot any othorauherizaon that allows, Information, Tis means, among other tings, hat you wi (1) -Atsentresporsilty forall activites undersken using your Ifermounin usomama and pessword, acces codes, and ‘thor eutherizaon; 5 and (2) Report any suspcon or enowiedge that you have that your Itsmmountain usarname and password, aesess dss, authorization, of any Confdentalinforotion has boon istaod or cscosed witout ifermountai's permission ‘tis suspicion of mowed the Intermountain Gomplence Hotine 2t 1-200-442-4885, off youre a member of lntermunsin'¢ Woreforeo to your uporvaor or fasty compliance offer); Not remove Co Information fom an irtermourtan facity unless necessary for your legitimate and Intermourtan- ‘approved responsbiiis(F removal cf Confdent Information from an Intermountain fect f necessary, you wil uso ‘easonebe and te physical and technical sefeguards-such as encrypting electronic Confdentalnfomaton or ensuring CGonfental information| nc lftin plain sight in car); Report acts by any ndvdual or enty tha you suspect may compromise the confidently of Confidertal Infomation (To the || extent permitted by law, ntemountain will holdin confidence reports that ae made in god faith about suspost actos, 2 well es he names of the ind\iduas reporting the activites.) "Not use or share Confiental Information aftr termination of your rl that tiggered the requiremontto sign this Agreement [Ft |) example, you ar a ‘Member, when you leve ntermountain's Worlforce; you are a Provider, when you lose your [tvleges at an itermodniai fcity or your prvieges to access Confidential Infermation andf you area Vendor or Agent, when Youinich your assignment projact win nlornountain or when your company siopsdolag business with Intermountain, ‘whichever is frst: and a | Pan 24 4 32 33 34. an ‘SECTION 3.0. VIOLATION OF DUTY -GHANGE OF STATUS Responsibility. You are resporsibe for your roncompkance wih his Agreement. Dstipine. fou val ary provsion otis Agreement, you wl be subect to consoqueras, including but notlinged to, the fling: ‘A you area Worktorse Member, dlsnisal asa member of itomounti’s Werkote, lose of anploymentwth Internourian, ‘ermatin of your ebity to aocess Corfdentia Ironraton, and legal iby, BL) you crea Provider, Vendor, Agent, or Resource Uso, discipline, inkuding rovoetion of your bly to acooss or use || Confident nformeton,andegal abit. Rall. Any vclation by you of any proviion ofthis Agreement wil cause nepeable irur to Intermountain thal would not be adoquatoly ‘onenseble fh monetary damages alone or trough tne legal remedies. and wl ent ifernountain to fo flowing: ‘A you area Wordoree Mombor, Vandor, Agent, or Resource User, preliminary and permanent injuncive rel, temporary ‘estalning ores, ard oer equitable ein aditon fo damagos ad eferiepal rads: or 8.) you ae Provider, 3 cout ove prohibting your uso of ConfdentalInformaton except es permite by this Agreement, and Intermeuntain may aso Seek oer remedies. Atri. Itermourtin may fermiate your ances to Confident information it your stats 2 a Wororce ember, Prove, Vendot Aged, cr Resource User ctanges, il Itemouniandeteines that to tein the bestingorests of hteemcuntie mean, o you vole ‘tly provision his Agreemont ‘SECTION 4.0, CONTINUING OBLIGATIONS Cautinung Obtgatos. You otiaton under ts Aguero con fe mine four mtostip wth homens 8 ree Member, Provider, Vendor, Agent, o: Resource User. Prntedtene:__ “Fealeio lanveri Siete (Drm dae:_OD[0C | 24 Revie: 62017 Student/Trainee Confidentiality Guideline Summary of Intermountain Health's Privacy Policies ‘Protecting patients’ privacy has always been an ethical reqnirement at Intermountain Health. It is also a federal law that care ‘Provides protect and ws patient information only for certain purposes. Asa student or tinge in Tutermouniain Health's facilities, ‘We require that you abide by out privacy practices. If you have questions about Intermountain Health’s privacy practices, please ‘contact§jour instmactor or Intermountain Health’s Corporate Compliance Hotline at 1-800-442-4845. ‘Handling Protected Health Information Protested Health Information intludes all medical, billing, and payment records that identity patients. Paper records, electronic We! We! Paties ‘records and ral commanication can contain protected health information. Failure to propenly protect patient information may result ‘Verbal or written wamings. ‘Suspension or expulsion from your educational institution (if stuem). ‘The terminstion of your educational experience or training at Intermountain. Legal liability for yourself, your educational institution (student), employer (ifprofessional tainee), and/or Intermountain Heath. Do Follow Intermountain Health procedures forthe release of protected health information. Limit the staring of protected health information by taking precautions such as not having conversations about a petit in public reas Keep medical, billing and payment ‘Adk questions when we ag not sure Dont Shave patient information yaless it ic for logitimatc basineas or patient care parposcs. Stace more health information than i appropriate forthe situation, ‘Share passwords ‘Use data dat identifies a specific pationt ina presentation. ‘Acgcss patient records unieas we have a legitimate assignment to do so. “Make copies of protected health information unless authorized to do 80, {Use personal cell phones 1a photograph patients. Shave information about patients, even nowideatified patients, with fanily members, fiends, or on social media sites. nts" Rights Federal regulations define specific patient rights. ‘To follow these regulations, Intermountain: Ensures that a patient ean ge copies of Intermountain Hoalth’s Notic of Privacy Practices that explainshow we may use and she protected health information and the patient's rights. Allows patients to inspect and obtain a copy of their health information as penmitod by In. ‘Accommodates requests Ly patients in how they want us to communicate with them. Allows patients to seek a restriction on the wse of their protected health informstion by Intermoustain. Allows paiients 1 request additions or comections to thee health information. “Tragks oveasions when we share protected health information ouside of Intermountain Health for certain purposes and provide A ligt ofthese disclosures toa patient on request, Provides apatint with the contact informaticn for Inermountain Health's Privacy Office andor the U.S. Department of Health snd Human Services whon an individual wishes to file « complaint. {informs the patient if there is s breach of their protoctd health information, ‘Willnot ake action against apatient who files a legitimate privacy related complaint with ws or the U.S. Department of Health and Human Services. in secure areas or on secure computer systems, appropriate to release information, "andes hav red atnadertnd the decent fabio opp Vanes pee an) Wlonnn— ___ortos\2y_ ‘Seion Afiiaioa Intermountai Health Revised 2021 Intormountain Health ‘Student Name: Medical Incident and Disease Exposure Student Training Release of Liability 0 be submitted to Intermountain Health prior to Commencing any Required onsite Training Activity _Falsio_kopy Vanu22 Phones: BOA THe *V42- ‘Name of SchooV/Insttution: Phone #: School/insttution Training Program: Facility(ies): understand that there are inherent potential health risks associated with my onsite educational experience [My jnitials signify Uhave read, understand, and agree with the following: Q jos (‘Training Program”) in the clinical leaming environment st Intermountain Health; these risks remain Jenl. el, Je det pak and/or may be increased as they relate to, but are not limited to, injuries, unintended accidents, and ‘comamunicable discase exposure (¢g., tuberculosis, HIV, COVID-19, etc). In consideration of being allowed to participate in a Training Program at Intermountain Health I do hersby waive, release, and forever discharge Intermountain Health and its officers, agents, employees, representatives, executors, and all others ftom any and al responsibilities or liability from injuries or damages from my participation inthe ‘Training Program. Ido also hereby telease all of those mentioned and any others acting upon their behalf from any responsibility or liability for any injury or damage to myself, arising out of or comecied with my participation in the Training Program. ‘understand that jf I choose not to or am unable to resume my Training Program 2s it becomes available, I ‘may request a lcaye of absence from my SchooV Institution to beallowed to complete my Training Program ata later date. I understand that this may impact my timeline for progression toward graduation. I further understand that my return to my Training Program is dependent upon agreement to my return by Intermountain Health. Granting a leave of absonco is atthe sole discretion of my SchooVInstitution, understand that [am encouraged not to resume the Training Program if feel Tam at incroasod risk duc to Personal oc health issues, and that I may request a leave of absence from my School/Institution to be allowed to complete my Training Program ata later date upon agreement to my return by Intermountain Health. I further understand that in granting a leave of absence my SchooV/Iasttution may choose to alter the timeline of my progression toward graduation oro substitute an equivalent activity to fulfill graduation requirements. Granting a leave of absence is at tho sole discretion of my School/astitution. | understand that Iam only permitted to resume the Training Program if | donothave symptoms of illness and receive approval by Intermountain Health. understand that if develop symptoms of illness, I must contact Intermountain Health and must comply with ll directions related to Intermountain Health infectious disease protocols. Imust also simakaneously voniact my respective ctinical team, course director(s), coordinator(s) and, as appropriate, my ‘SchooVInstitution’s representative. understand my right disease testing end how to access/reocive appropriate testing in the event develop symptoms suggestive of a communicable disease infection. Lalso understand that [may be responsible for any costs associated with such testing, agree to comply with the policies and procedures, including health screening practices, for entry into any Intermountain Health facility. fous understand and agree that if Thave participsted in recent sctivities* that place me at increased risk for 8 it” communicable diseases exposure and subsequent infection, I might be required to complete a period of ‘quarantine in accordance with current CDC, Utah Department of Health, or Intermountain policies prior to pavticipating in any Training Program. ‘Examples include, but are not limited to: unprotected close coniact with individuals who have @ communicable diseases infection; unprotected close contact with individuals with an uaknown communicable discase status (such as during extended travel); unprotected close contact with extended family members or social acquaintance; among other activities with potential risk for a communicable diseases expostre. Fret [understand that while in the clinical environment at Intermountsin Health, I must follow the safety ‘wits! measures and infectious disease protocols such as appropriate hand hygiene at all times. oe ftequired for my Training Program, any PPE provided by the School/Institution or myself (ic. masks) sia), must be approved prior to use by Facility Infection Prevention or Industrial Hygiene teams. FAO seis ets ne | ER en ‘ati must ask them fo wear a mask or cover their nose and mouth. fo, ‘attest that I have or will complete any and sll approved training required by Intermountain Health. {understand that failure to comply with Intermountain Heath's policies, procedures, expectations, traning, and practices outlined in this document will automatically suspend me from participating in a Training Program at Intermountain Health. Intermountain Health will report this suspension tomy SchooV/Institusion and will provide fall documentation of my behavior to my School/institution’s disciplinary and ‘professionalism oommittoos, gual Tada tl isc sci caa cea e ho Signature of Student: poem —— __ Date oro ey Seams iRise rar Student Orientation Quiz Open book. Retake required if student misees more than two questions. Final score: 130 1. The mission of Intermountain Health ts: Helping. live the, possible. Patints, Best, Lives 5. Everyone, Intemnointan, Experience People, Heahiest Lives 4. Patents Healthiest, Where 2. What are the vaiues of infarmountaln Heath? a. Weare leaders in dinical excellence; We believe in what we do ». We serve with empathy, We are partners in health c, Wedo the right thing; We are better together 7A Nocti bore ‘3. flntormountain fs not meeting thelr mission, vision and values, the method of lodging a concern is: YK Tellyournstuctor "9K Call the Compliance Hotline ‘Tell your procoptor 4. Talkto patients cllonts 4. Complete the following statement:

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