<p> INTERN MANDATORY CHECKLIST</p><p>Intern Name: ______BH Placement Site: ______School and/or Program Name:______Instructor Name: ______</p><p>Internship Packet Includes: 1. Intern Data 2. Health Screening Form & Waivers 3. Varicella Guidelines 4. Hepatitis B Vaccine Guidelines & Waiver 5. “Mandatory Inservice for Non-Hospital Personnel” Quiz 6. Student Agreement & Acknowledgement Form a. Information has been read, acknowledged, and checked b. Signature, printed name, and dated 7. Criminal Background Check Authorization Form</p><p>Student Placement Approval Section  Mandatory Checklist – Student has completed paperwork and has been approved to receive a Tuberculosis Skin Test from Employee Health</p><p>Date: ______HR Staff Signature: ______</p><p>Employee Health Section: Two-step Tuberculosis Test (TST): One step must be completed by Bloomington Hospital Employee Health Services. Documentation of TST from another facility will be accepted as 2nd step. Or, second step must be completed within 1-3 weeks after beginning internship.</p><p> First step Placement Date: ______EH Staff Initials: ______</p><p> First step Reading Date: ______</p><p>Employee Health Staff Signature:______</p><p>*Checklist must be returned to Human Resources upon completion of the first TST reading. Badge will be issued at that time. </p><p>HUMAN RESOURCES SECTION:  Hospital I.D. Badge Issued</p><p>Date: ______HR Staff Signature: ______</p><p>1 INTERN PACKET Please complete this packet and carefully read the policy references as they are important to make your internship experience safe for our patients, staff, and you! By signing the Agreement/Acknowledgement statement at the end of this packet, you agree that you understand these policies and agree to abide by them. Therefore, please be sure to read everything thoroughly before signing the checklist at the end of this packet. 1. Intern Data</p><p>Name: ______Last First Middle</p><p>Current Address: ______</p><p>City: ______State: ______Zip: ______</p><p>Permanent Address: ______</p><p>City: ______State: ______Zip: ______</p><p>E-Mail Address: ______</p><p>___Female ___Male Telephone Number: (______) ______</p><p>Date of birth: ______/______/______Social Security #: ______/ ______/ ______</p><p>School/University and Program: ______</p><p>Placement Dates at Bloomington Hospital: ______</p><p>Department(s)/Unit(s) in which you are completing internship: ______</p><p>In an Emergency Notify:</p><p>Name: ______Phone: (_____) ______</p><p>Relationship to you: ______Cell/beeper: (_____) ______</p><p>2. Health Screening Form & Waivers As Bloomington Hospital develops contracts with higher education health care focused student programs, it is important to assure that State and Federal health care worker requirements are met. Because the vaccine preventable disease and TB status of students are also infection control issues, Dr. Tom Hrisomalos was consulted in the development of recommendations listed below. The same employee vaccine and TB testing standards apply to students. Individuals who respond “yes” to following questions must be cleared by the Employee Health Services prior to beginning activities at Bloomington Hospital. Screening Questions: Must Circle One (Yes or No) for each question:</p><p>I have had contact with an individual: 1. With active tuberculosis within the last 12 weeks. Yes / No 2. With active case of chickenpox within the last 30 days. Yes / No 3. That has/had a communicable disease within the last 30 days (i.e. SARS, Measles, etc.). Yes / No If yes, please explain: ______</p><p>I currently have the following symptoms: 1. Persistent productive cough of 2 weeks or longer Yes / No 2. Night sweats Yes / No 3. Fever Yes / No 4. Open skin lesions Yes / No</p><p>2 All Interns must provide Bloomington Hospital up-to-date immunization records from educational institution or healthcare provider, including the following: MMR (check one):  Documentation of 2 MMR  Documentation of Positive Rubella IgG, Rubeola IgG, and Mumps IgG (blood tests)</p><p>Tetanus, Diphtheria, Pertussis Vaccine (Tdap) Adecel:  Yes, I have provided documentation of Tdap vaccine (Strongly recommended for all direct patient care providers, including internship students)  No, I have no provided documentation of Tdap vaccine</p><p>Tuberculosis Screening: (check one)  Documentation of a negative (Omm) TST within the past 12 months, and one negative (Omm) TST completed by BH Employee Health Services  Two negative (Omm) TSTs completed by BH Employee Health Services, 1-3 weeks apart, immediately before starting internship  Documentation of T-SPOT or quantiFERON – TB Gold blood tests for TB screening within 30 days of start date</p><p>Documented History of positive Tuberculosis Skin or Blood Test:  Negative chest x-ray, followed by annual screening for signs and symptoms of active tuberculosis disease. 3. Varicella (Chickenpox) Guidelines & Waiver *Everyone must check one box below. Medical documentation must be provided to Bloomington Hospital of: History of Chickenpox or herpes zoster (shingles), Positive Varicella IgG, or Varicella vaccination.</p><p> I have provided documentation of physician/nurse practitioner/physician assistant-diagnosed Chickenpox disease or herpes zoster (shingles) with this packet.</p><p> Vaccinated Student: I have been vaccinated with two doses of varicella vaccine (Varivax) at least one month apart, and have provided the record with this packet. I understand that breakthrough infections (cases of chickenpox) have occurred among vaccinated individual after exposure to individuals with chickenpox disease. It is my responsibility to immediately notify Bloomington Hospital Employee Health Services of chickenpox exposures at or away from the facility.</p><p> I have provided documentation of a positive Varicella IgG blood test with this packet. 4. Hepatitis B Vaccine Guidelines & Waiver *Everyone must check one box below. </p><p> I have provided documentation with this packet of completion of the three-step Hepatitis B Vaccine series and a positive Hepatitis B surface Antibody blood test drawn at least 4 weeks after the third vaccination.</p><p> I am currently receiving the Hepatitis B vaccine series. I will provide documentation of completion of the three-step Hepatitis B vaccine series and a positive Hepatitis B surface antibody blood test drawn at least 4 weeks after the third vaccination.</p><p> I decline the Hepatitis B Vaccine because (circle one): a. I understand that, due to my occupational exposure to blood and other potentially infectious materials, I may be at risk of acquiring Hepatitis B Virus (HBV) infection. Bloomington Hospital has strongly advised that I visit a healthcare provider and obtain the Hepatitis B Vaccine. However, I decline Hepatitis B Vaccination at this time. I understand that by declining this vaccine I continue to be at risk of acquiring Hepatitis B, a serious disease. b. The vaccine is contraindicated for medical reasons. Explain: ______c. I do not anticipate occupational risk of exposure to blood and other potentially infectious materials.</p><p>3 5. “Mandatory Inservice for Non-Hospital Personnel” Quiz</p><p>1. Who is the Safety Officer for Bloomington Hospital? a. Barney b. Rusty Rozelle c. Vickie VanDeventer d. The Lone Ranger</p><p>2. The Joint Commission Standards require Bloomington Hospital to develop _____ Environment of Care Plans. a. 5 b. 6 c. 7 d. 8</p><p>3. If a patient discloses personal information to a healthcare provider, the healthcare provider may reveal this information to anyone without the consent of the patient. True False</p><p>4. Every patient has a right to receive considerate and respectful care. True False</p><p>5. Diversity is: a. Group & individual differences b. Reducing standards c. Distraction from important business</p><p>6. What are the four components of the F.A.I.R. Approach? a. Feedback, Alliance, Instruct, Respect b. Feedback, Assistance, Inclusion, Respect c. Fortitude, Association, Inclusion, Respect d. Finance, Assistance, Instruct, Reliance</p><p>7. Cultural Competence means: a. Recognizing and responding to our similarities and differences to make better decisions b. Helping to adjust and adapt to the changes around us c. Keeping the competitive edge to anticipate the customers needs d. All of the above</p><p>8. How do you report a fire? a. Call 44 or 911 to report (Depending on building location, check department specific plan for instructions). b. Yell down hallways to alert staff and visitors. c. Call the operator by dialing “0”. d. Don’t worry. Someone else will do it.</p><p>9. The first step of the Bloomington Hospital Fire Plan is: a. Call the operator b. Remove all patients from immediate danger c. Pull the alarm box d. Grab the nearest fire extinguisher, and extinguish the fire (if safe to do so)</p><p>10. A Code Black is implemented when: a. An infant abduction is suspected b. A severe thunderstorm warning is in effect c. There is a confirmed report of a tornado being sighted and the Bloomington area is in imminent danger d. An external disaster has occurred</p><p>11. Hazardous Communication Standard applies to any chemical substance present in the workplace, including those, which are used more frequently or for a longer duration than they would in normal consumer use. True False</p><p>12. In the event that there is a power failure, which outlets are supplied with power from our emergency generators? a. All outlets have power c. All the outlets on the first and second floors b. The red outlets d. The green outlets</p><p>13. The Hospital has agreements with local vendors to provide backup utilities. True False</p><p>14. All new Medical Equipment must be evaluated prior to use by: a. Clinical Engineering c. Joint Commission on Accreditation of Healthcare Organizations b. Risk Management d. The State Fire Marshall</p><p>15. If there is a death, illness or injury that may have been caused by a medical device; do all of the following, except: a. Save the device & all packaging c. Contact Clinical Engineering or Risk Management b. Fill out HITS report immediately d. Continue to use the device</p><p>16. The #1 intervention you can implement to prevent the spread of infection is: a. Use a Kleenex b. Wash your hands c. Take vitamins d. Exercise</p><p>4 6. Student Agreement & Acknowledgement Form: Confidentiality Agreement As a student intern or volunteer of Bloomington Hospital, I recognize the extreme importance of confidentiality with respect to information concerning patients, Bloomington Hospital operations, and employees / Human Resources. I acknowledge that I will adhere to the provisions of the Health Insurance Portability and Accountability Act (HIPAA) and any other federal or state laws regarding confidentiality. I understand that violations of confidentiality may result in legal action pursuant to HIPAA and other applicable state and federal laws.  All patient information (including personal, financial, and health information), as well as all information regarding Bloomington Hospital operations and employees / human resources, is confidential and any inappropriate viewing, discussion, or disclosure of this information is a violation of Bloomington Hospital policy.  This information is privileged and confidential regardless of format: electronic, written, overhead or observed.  I understand that violations of confidentiality will result in disciplinary action up to and including termination of employment, contract, association, or appointment. Disciplinary action may also include the imposition of fines and other legal action pursuant to HIPAA and other applicable state and federal laws.  I agree to report any violations of confidentiality that I become aware of to my supervisor, department director, member of the Senior Leadership Group, or the HIPAA Privacy Officer.  I have read and understand the information outlined in the “Confidentiality” section of the “Mandatory Inservice for Non-Hospital Personnel.” Ethics – Professionalism I understand, like staff, I cannot initiate telephone calls, write notes, or arrange social interactions with patients. I will clearly define boundaries of staff-patient relationships during chance meetings in the community. Any pre-existing relationships with patients are to be discussed with the Director of the Department. Should a discharged patient attempt to develop a personal relationship with me post-discharge, I will clearly define again the staff-patient relationship boundaries and report this to the Director, who will provide specific guidance for professional conduct. Violation of this policy is grounds for termination of my Shadowing experience. Hold Harmless Agreement & Waiver The undersigned, being an adult, does herby agree to release, indemnify, and hold harmless Bloomington Hospital, its employees, agents, and representatives from any and all damages of any nature whatsoever which the undersigned may suffer as a result of being a passenger in a Bloomington Hospital vehicle, including a BHAS emergency vehicle, owned or operated by Bloomington Hospital. The undersigned fully understands the risks involved in being a passenger in a Bloomington Hospital vehicle, including a BHAS emergency vehicle owned or operated by Bloomington Hospital, and assumes risk freely and voluntarily. This release indemnity and holds harmless is given by the undersigned in consideration of Bloomington Hospital granting permission to ride in a Bloomington Hospital vehicle, including BHAS emergency vehicle, owned or operated by Bloomington Hospital for training, observation and evaluation purpose of benefit to the undersigned. Smoking & Tobacco Use Policy - Human Resources Policy No. HR-8-111 Smoking and/or use of tobacco products will not be allowed on the Bloomington Hospital campus (including: in buildings or in vehicles owned and operated by Bloomington Hospital). This includes all satellite buildings and the property associated with those satellites. All tobacco products, including chewing tobacco and snuff, are included in the policy. Violation of this policy may result in termination of internship experience. Customer Loyalty Standards I have read the guidelines and agree to adhere to the Customer Loyalty standards as outlined in the “Mandatory Inservice for Non-Hospital Personnel” under the student web page. Parking I have read the guidelines and agree to adhere to the Bloomington Hospital Student Parking guidelines as outlined under the Student Website. Personal Appearance & Dress Code As a clinical student you are expected to follow the dress code set forth by Human Resources Policy 8-115 and Appendix N Personal Appearance Chart. Items NOT allowed under dress code: denim jeans, shorts, sleeveless blouses, sandals, or any attire that shows undergarments. Jewelry and perfume scents should be kept to a minimum. Items recommended: appropriate scrubs (check with assigned area to determine color of scrubs) or business casual attire (Example: khaki pants, a nice shirt, clean & comfortable tennis shoes). Read this statement carefully before signing: All preceding answers in this packet are true to the best of my knowledge and I understand this will become a part of my record. I also understand that any incorrect, incomplete, false, or misleading statement or information by me herein will be considered possible cause for my dismissal from my student experience. Furthermore, I understand that the Health Screening is not a physical examination. The hospital is not assuming responsibility for my continued medical care. I have read and understand the preceding policies. I am aware that if I violate a Bloomington Hospital rule or regulation my clinical experience may be terminated immediately. Additionally, if I do not meet the Professional Appearance & Dress Code Policy on days in which I am scheduled for clinicals, I will not be allowed to complete the experience on that day. I will remember that the department may make special accommodations for my clinical experience. Therefore, if something happens and I am not available during the time that I have been scheduled for, then I MUST notify the department. Rescheduling arrangements may be discussed at this time or later. Student Agreement I have read, acknowledged, and agree to abide by the following (Check boxes and sign below):  I will keep all Protected Health Information as well as all information regarding Bloomington Hospital operations and employees/human resources confidential.  I will hold harmless Bloomington Hospital and its representatives from any damages obtained during student placement.  I will not use tobacco products or smoke on the Bloomington Hospital campus.  I will remember Customer Loyalty Standards and treat everyone that I encounter with respect.  I will follow Personal Appearance & Dress Code guidelines.  I will follow all immunization, health, and safety standards.  I will remember that we live and practice in a diverse community and have studied the information outlined in “Diversity at Bloomington Hospital” in the “Mandatory Inservice for Non-Hospital Personnel” on the student web page.  I have studied the “National Patient Safety Goals” on the student web page. Signature______Printed Name______Date______5 7. Criminal Background Check Authorization Form: *If you are under the age of 18, please disregard this form. Dear Student/Intern, You have been accepted for a non-paid internship or clinical rotation at a Bloomington Hospital site. Therefore, the hospital is obligated to run a criminal background check to ensure the safety of our patients, staff, and visitors. (A criminal background report may be provided to us by your college, university, or educational program if included within the Affiliation Agreement between Bloomington Hospital and your program.) Therefore, this page must be completed before you may begin your internship or clinical placement.</p><p>Full Name: ______</p><p>Birth Date: ______Social Security #: ______-_____-______</p><p>Please list your last two places of residence:</p><p>______Street City State Zip</p><p>______Street City State Zip</p><p>Gender: Race/Ethnic  Male Identification:  Native American  Female  Hispanic or or Other Pacific Latino Islander  White  American Indian  Black or African or Alaska Native American  Two or more  Asian races</p><p>Authorization for Procural of a Consumer Report by Bloomington Hospital As an applicant for employment, student internship or as a volunteer with Bloomington Hospital, Inc., I hereby acknowledge receipt of the written Disclosure of Potential Procural of a Consumer Report by Bloomington Hospital, Inc. I hereby authorize Bloomington Hospital, Inc.(the “Hospital”), to obtain a consumer credit report, including a criminal background check, regarding me for employment, student internship or volunteer purposes. I understand that before taking any adverse action against me based on whole or in part on the report, the Hospital must provide me with a copy of the report and a written description of my rights under the Consumer Credit Reporting Reform Act of 1996 (the “Act”), 15 U.S.C.A. §1681a et seq.</p><p>Signature: ______</p><p>Printed Name:______Date: _____/_____/_____</p><p>6</p>