Attestations. I have read and understand the meaning of confidentiality and the information that I must keep private while a student observer at the clinical sites of Forté Sports Medicine and Orthopedics as well as the surgery centers and hospitals. I understand that I am obliged to protect and maintain the confidentiality of this information at all times. I understand that my visit will potentially expose me to communicable and infectious diseases, injury from needles and other sharp articles, slips, falls, and other unforeseen incidents. I understand that if I am injured or exposed to a communicable disease or suspected of being injured or exposed to a communicable disease, I will be offered treatment according to Forté policy for such exposures and injuries. I will be held responsible for the medical expenses related to all treatment that is provided to me in such instances. I am immune to normal childhood diseases, including: Rubella (German measles) Rubeola (red measles) Varicella (chicken pox) either by: Natural means (diagnosed, documented, and signed by a licensed healthcare provider), immunity by laboratory results (positive titre) Vaccination (signed by licensed nurse or healthcare provider). Influenza vaccine (for current flu season September-March) PPD – TB test within 1 year Hepatitis B These immunities are documented and will be submitted during the application process. Please contact the observation manager if you have a religious exemption for immunizations. To safeguard the health of our employees and their families, our patients and visitors, and the community at large from COVID-19 that may be reduced by vaccination, antibodies, or prior exposure, the Forté observation program will require all participants to provide proof of COVID-19 vaccination. I am free of significant eye, skin, respiratory, gastrointestinal, or other communicable infections. This includes fever, cough, cold, cold sores, hepatitis A, lice, scabies, diarrhea, or recent exposure to communicable infections such as chicken pox (varicella), pertussis (whooping cough), or tuberculosis (TB). I am free of any skin rashes, including any reaction to recent chicken pox vaccination. I will comply with hand hygiene procedures by using soap and water/hand sanitizers before and after entering any patient room or treatment area, eating, and after using the restroom. I understand that if I become sick (including but not limited to fever, cough, diarrhea, vomiting, cold or flu), I will remove myself from the assignment, seek medical care as appropriate, and will not return with any communicable disease. I will not use or disclose Protected Health Information (PHI), as described in the Health Insurance Portability & Accountability Act (“HIPAA”). I will hold all patient information in strict confidence. I understand patient information, whether verbal, electronic, or hardcopy, is not to leave Forté premises, and I am not to discuss patient information with anyone other than the person I am shadowing. I understand that patient information includes not only patient names and other identifying information but also any information related to a patient's condition, treatment, presence at the hospital, or any other information I hear, observe, or learn about any patient or patient's family members during my visit. I understand that Forte will not provide transportation or meals while participating in the observation program. I understand the dress code requirements as listed above. Observers may be sent home immediately if their dress is not appropriate for the setting. On the day of observation, I must bring a photo ID I hereby release this facility, its employees, its agents and its medical staff and agree to hold them harmless from any and all actions and claims, not caused by their negligence, arising out of their good faith performance under this consent document. This agreement shall be effective when executed on behalf of both of the parties hereto and shall continue in full force and effect indefinitely.
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Attestations. I have read and understand the meaning of confidentiality and the information that I must keep private while a student professional observer at the clinical sites of Forté Methodist Sports Medicine and Orthopedics as well as the surgery centers and hospitals. I understand that I am obliged to protect and maintain the confidentiality of this information at all times. I understand that my visit will potentially expose me to communicable and infectious diseasesdisease, injury from needles and other sharp articles, slips, falls, slips and falls and other unforeseen incidents. I understand that if I am injured or exposed to a communicable disease disease, or suspected of being injured or exposed to a communicable disease, I will be offered treatment according to Forté MSM policy for such exposures and injuries. I will be held responsible for the medical expenses related to all treatment that is provided to me in such instances. I am immune to normal childhood diseases, diseases including: Rubella (German measles) Rubeola (red measles) Varicella (chicken pox) either by: Natural means (diagnosed, documented, and signed by a licensed healthcare provider), immunity by laboratory results (positive titre) Vaccination (signed by licensed nurse or healthcare provider). Influenza vaccine (for current flu season September-March) PPD – TB test within 1 year Hepatitis B These immunities are documented and will be submitted during the application processpresented on date of observation. Please contact the observation manager if you have a religious exemption for immunizations. To safeguard the health of our employees and their families, our patients and visitors, and the community at large from COVID-19 that may be reduced by vaccination, antibodies, or prior exposure, the Forté observation program will require all participants to provide proof of COVID-19 vaccination. I am free of significant eye, skin, respiratory, gastrointestinal, or other communicable infections. This includes fever, cough, cold, cold sores, hepatitis A, lice, scabies, diarrhea, diarrhea or recent exposure to communicable infections such as chicken pox (varicella), pertussis (whooping cough), or tuberculosis (TB). I am free of any skin rashes, including any reaction to recent chicken pox vaccination. I will comply with hand hygiene procedures by using soap and water/hand sanitizers before and after entering any patient room or treatment area, eating, and after using the restroom. I understand that if I become sick (including but not limited to fever, cough, diarrhea, vomiting, cold or flu), I will remove myself from the assignment, seek medical care as appropriate, appropriate and will not return with any communicable disease. I will not use or disclose Protected Health Information (PHI), as described in the Health Insurance Portability & Accountability Act (“HIPAA”). I will hold all patient information in strict confidence. I understand patient information, whether verbal, electronic, or hardcopy, is not to leave Forté MSM premises, and I am not to discuss patient information with anyone other than the person I am shadowing. I understand that patient information includes not only patient names and other identifying information information, but also any information related to a patient's condition, treatment, presence at the hospital, or any other information I hear, observe, or learn about any patient or patient's family members during my visit. I understand that Forte MSM will not provide transportation or meals while participating in the observation program. I understand the dress code requirements as listed above. Observers may be sent home immediately if their dress is not appropriate for the setting. On the day of observation, I must bring a bring: A photo ID Proof of immunizations listed in #2. I hereby release this facility, its employees, its agents and its medical staff and agree to hold them harmless from any and all actions and claims, not caused by their negligence, arising out of their good faith performance under this consent document. This agreement shall be effective when executed on behalf of both of the parties hereto and shall continue in full force and effect indefinitely.
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Attestations. I have read and understand the meaning of confidentiality and the information that I must keep private while a student observer Intern at the clinical sites of Forté Methodist Sports Medicine and Orthopedics as well as the surgery centers and hospitals. I understand that I am obliged to protect and maintain the confidentiality of this information at all times. I understand that my visit will potentially expose me to communicable and infectious diseasesdisease, injury from needles and other sharp articles, slips, falls, slips and falls and other unforeseen incidents. I understand that if I am injured or exposed to a communicable disease disease, or suspected of being injured or exposed to a communicable disease, I will be offered treatment according to Forté MSM policy for such exposures and injuries. I will be held responsible for the medical expenses related to all treatment that is provided to me in such instances. I am immune to normal childhood diseases, diseases including: Rubella (German measles) Rubeola (red measles) Varicella (chicken pox) either by: Natural means (diagnosed, documented, and signed by a licensed healthcare provider), immunity by laboratory results (positive titre) Vaccination (signed by licensed nurse or healthcare provider). Influenza vaccine (for current flu season September-March) PPD – TB test within 1 year Hepatitis B These immunities are documented and will be submitted during the application processpresented on date of observation. Please contact the observation manager if you have a religious exemption for immunizations. To safeguard the health of our employees and their families, our patients and visitors, and the community at large from COVID-19 that may be reduced by vaccination, antibodies, or prior exposure, the Forté observation program will require all participants to provide proof of COVID-19 vaccination. I am free of significant eye, skin, respiratory, gastrointestinal, or other communicable infections. This includes fever, cough, cold, cold sores, hepatitis A, lice, scabies, diarrhea, diarrhea or recent exposure to communicable infections such as chicken pox (varicella), pertussis (whooping cough), or tuberculosis (TB). I am free of any skin rashes, including any reaction to recent chicken pox vaccination. I will comply with hand hygiene procedures by using soap and water/hand sanitizers before and after entering any patient room or treatment area, eating, and after using the restroom. I understand that if I become sick (including but not limited to fever, cough, diarrhea, vomiting, cold or flu), I will remove myself from the assignment, seek medical care as appropriate, appropriate and will not return with any communicable disease. I will not use or disclose Protected Health Information (PHI), as described in the Health Insurance Portability & Accountability Act (“HIPAA”). I will hold all patient information in strict confidence. I understand patient information, whether verbal, electronic, or hardcopy, is not to leave Forté MSM premises, and I am not to discuss patient information with anyone other than the person I am shadowing. I understand that patient information includes not only patient names and other identifying information information, but also any information related to a patient's condition, treatment, presence at the hospital, or any other information I hear, observe, or learn about any patient or patient's family members during my visit. I understand that Forte MSM will not provide transportation or meals while participating in the observation program. I understand the dress code requirements as listed above. Observers Interns may be sent home immediately if their dress is not appropriate for the setting. On the first day of observationInternship, I must bring a bring: A photo ID Proof of immunizations listed in #2. I hereby release this facility, its employees, its agents and its medical staff and agree to hold them harmless from any and all actions and claims, not caused by their negligence, arising out of their good faith performance under this consent document. This agreement shall be effective when executed on behalf of both of the parties hereto and shall continue in full force and effect indefinitely.
Appears in 1 contract
Attestations. I have read and understand the meaning of confidentiality and the information that I must keep private while a student observer at the clinical sites of Forté Sports Medicine and Orthopedics as well as the surgery centers and hospitals. I understand that I am obliged to protect and maintain the confidentiality of this information at all times. I understand that my visit will potentially expose me to communicable and infectious diseases, injury from needles and other sharp articles, slips, falls, and other unforeseen incidents. I understand that if I am injured or exposed to a communicable disease or suspected of being injured or exposed to a communicable disease, I will be offered treatment according to Forté policy for such exposures and injuries. I will be held responsible for the medical expenses related to all treatment that is provided to me in such instances. I am immune to normal childhood diseases, including: Rubella (German measles) Rubeola (red measles) Varicella (chicken pox) either by: Natural means (diagnosed, documented, and signed by a licensed healthcare provider), immunity by laboratory results (positive titre) Vaccination (signed by licensed nurse or healthcare provider). Influenza vaccine (for current flu season September-March) PPD – TB test within 1 year Hepatitis B These immunities are documented and will be submitted during the application process. Please contact the observation manager if you have a religious exemption for immunizations. To safeguard the health of our employees and their families, our patients and visitors, and the community at large from COVID-19 that may be reduced by vaccination, antibodies, or prior exposure, the Forté observation program will require all participants to provide proof of COVID-19 vaccination. I am free of significant eye, skin, respiratory, gastrointestinal, or other communicable infections. This includes fever, cough, cold, cold sores, hepatitis A, lice, scabies, diarrhea, or recent exposure to communicable infections such as chicken pox (varicella), pertussis (whooping cough), or tuberculosis (TB). I am free of any skin rashes, including any reaction to recent chicken pox vaccination. I will comply with hand hygiene procedures by using soap and water/hand sanitizers before and after entering any patient room or treatment area, eating, and after using the restroom. I understand that if I become sick (including but not limited to fever, cough, diarrhea, vomiting, cold or flu), I will remove myself from the assignment, seek medical care as appropriate, and will not return with any communicable disease. I will not use or disclose Protected Health Information (PHI), as described in the Health Insurance Portability & Accountability Act (“HIPAA”). I will hold all patient information in strict confidence. I understand patient information, whether verbal, electronic, or hardcopy, is not to leave Forté premises, and I am not to discuss patient information with anyone other than the person I am shadowing. I understand that patient information includes not only patient names and other identifying information but also any information related to a patient's condition, treatment, presence at the hospital, or any other information I hear, observe, or learn about any patient or patient's family members during my visit. I understand that Forte will not provide transportation or meals while participating in the observation program. I understand the dress code requirements as listed above. Observers may be sent home immediately if their dress is not appropriate for the setting. On the day of observation, I must bring a photo ID I hereby release this facility, its employees, its agents and its medical staff and agree to hold them harmless from any and all actions and claims, not caused by their negligence, arising out of their good faith performance under this consent document. This agreement shall be effective when executed on behalf of both of the parties hereto and shall continue in full force and effect indefinitely.
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