Intern Packet by nHyoND3


									                      INTERN MANDATORY CHECKLIST
Intern Name: ________________________________________________________________
Placement Site/Location: __________________________________________________
School and/or Program Name: ___________________________________________
Instructor Name: _____________________________________________________

  Internship Packet Includes:
      1. Intern Data
      2. Health Screening Questions
      3. Required Immunizations
      4. Influenza Declination Form
      5. “Mandatory In-service for Non-Hospital Personnel” Quiz
      6. Student Agreement & Acknowledgement Form
      7. Criminal Background Check Authorization Form

  Student Placement Approval Section
      Mandatory Checklist – Student has completed paperwork and has been approved to receive a
        Tuberculosis Skin Test from Employee Health

  Date: ______________ HR Staff Signature: _____________________________

  Employee Health Section:
  Two-step Tuberculosis Test (TST): One step must be completed by IU Health Bloomington Employee Health
  Services. Documentation of TST from another facility (must include date & time) will be accepted as the 1st

      First step Placement Date & Time: ___________            EH Staff Initials: ____________

      First step Reading Date & Time:      ___________

  Employee Health Staff Signature:________________________________________

  *Checklist must be returned to Human Resources upon completion of the first TST reading. Badge will be
  issued at that time.

      Hospital I.D. Badge Issued
  Date: ______________ HR Staff Signature: ______________________________

                                                      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
Name: _________________________________________________________________________________________
       Last                                First                               Middle

Current Address: _________________________________________________________________________________

City: ___________________________            State: _______________ Zip: __________________________________

Permanent Address: _______________________________________________________________________________

City: ___________________________            State: _______________ Zip: __________________________________

E-Mail Address: __________________________________________________________________________________

___Female     ___Male                        Telephone Number: (________) __________________________________

Date of birth: _______/_______/_______                Social Security #: ________/ ________/ __________

School/University and Program: ______________________________________________________________________

Placement Dates: __________________________________________________________________________________

Department(s)/Unit(s) in which you are completing internship: ______________________________________________

In an Emergency Notify:

Name: __________________________________________                Phone: (_____) ________________________________

Relationship to you: _______________________________ Cell/beeper: (_____) ____________________________

                                               2. Health Screening Questions
As IU Health Bloomington 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 IU Health Bloomington.

Screening Questions: Must Circle One (Yes or No) for each question:

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: _____________________________________________________

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

                                                3. Required Immunizations

All Interns must provide IU Health Bloomington up-to-date immunization records from their educational
institution or healthcare provider, for the following (one box must be checked in each area):

 MMR:
     Documentation of 2 MMR
     Documentation of Positive Rubella IgG, Rubeola IgG, and Mumps IgG (blood tests)

 Varicella (Chickenpox):
   I have provided documentation of a positive Varicella IgG blood test with this packet.
   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 IU Health
    Bloomington Employee Health Services of chickenpox exposures at or away from the facility.

 Hepatitis B Vaccine:
   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).

     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

     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. IU Health Bloomington 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

 Tetanus, Diphtheria, Pertussis Vaccine (Tdap) Adecel:
    Please Note: The Dtap vaccine can not be accepted as the Tdap. Tdap vaccines before 2005 will not be accepted.
     Yes, I have provided documentation of Tdap vaccine
     I have provided a medical waiver due to personal health history

 Influenza (Flu) Vaccine:
   I have provided documentation of a current flu vaccination (given during this season)
   I decline the vaccination at this time and I’ve filled out the attached Declination Form.

 Tuberculosis Screening:
   Documentation of a negative (Omm) TST within the past 12 months (must include date & time of placement &
        reading), and one negative (Omm) TST completed by IU Health Employee Health Services
       Two negative (Omm) TSTs completed by IU Health 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

     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.

                           4. 2011 Influenza Vaccination Declination Form
Please complete the gray sections if declining the Influenza Vaccine after reading the content below.

Print Name:___________________________________ Employee ID#___________________

Please check one:  Employee  Medical Staff  Volunteer at _________________________
                      Student  Contract  Other__________________________________
Indiana University Health has recommended that I received the influenza vaccination to protect the
patients I serve.

I acknowledge that I am aware of the following facts:
     Influenza is a serious respiratory disease that kills an average of 36,000 persons and hospitalizes
       more than 200,000 persons in the United States each year.
     Influenza vaccination is recommended for me and all other healthcare workers to protect our
       patients from influenza disease, its complications, and death.
     If I contract influenza, I will shed the virus for 24-48 hour before influenza symptoms appear. My
       shedding the virus can spread influenza disease to patients in this facility
     If I become infected with influenza, even when my symptoms are mild or non-existent, I can spread
       the illness to others.
     I understand the strains of the virus that cause influenza each year change almost every year,
       which is why a different vaccine is recommended each year.
     I understand I cannot get influenza from the influenza vaccine.
     The consequences of my refusing to be vaccinated could have life-threatening consequences to my
       health and the health of those whom I have contact including
           o My patients and other patients in this healthcare setting
           o My coworkers
           o My family
           o My community

Despite these facts, I am choosing to decline influenza vaccination right now for the following
reasons: Please choose the reason/s for declination
Valid (evidence based) reasons for declination         Not valid (not evidence based) reasons for declination

    Severe egg allergy or severe allergy to any              Afraid of shots
     component of the vaccine                                 Afraid I will get ill from the vaccine
    History of Guillian-Barre Syndrome                       Never taken the vaccine
    Received vaccine elsewhere                               Afraid of side effects
     facility____________________                             Pregnancy

**2012-2013 Influenza vaccine will be MANDATORY for all Employee’s, Volunteer’s, Contract Worker’s, Medical
Staff & Students. If you are unable to receive vaccine due to a medical contraindication a physician’s statement
must be provided.


                              5. “Mandatory In-service for Non-Hospital Personnel” Quiz
1. Who is the Safety Officer for IU Health Bloomington?
        a. Barney          b. Rusty Rozelle           c. Vickie VanDeventer                  d. The Lone Ranger

2. The Joint Commission Standards require IU Health Bloomington to develop _____ Environment of Care Plans.
         a. 5            b. 6               c. 7            d. 8

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

4. Every patient has a right to receive considerate and respectful care.
        True                                    False

5. Diversity is:
        a. Group & individual differences           b. Reducing standards        c. Distraction from important business

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

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

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.

9. The first step of the IU Health Bloomington 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)

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

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

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

13. The Hospital has agreements with local vendors to provide backup utilities.
        True                                           False

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

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

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

                                            6. Student Agreement & Acknowledgement Form:
Confidentiality Agreement
As a student intern of IU Health Bloomington, I recognize the extreme importance of confidentiality with respect to information concerning patients, IU Health
Bloomington 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 IU Health Bloomington operations and
           employees / human resources, is confidential and any inappropriate viewing, discussion, or disclosure of this information is a violation of IU Health
           Bloomington 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
          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 In-service 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 IU Health Bloomington, 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 IU Health Bloomington vehicle, including a BHAS
emergency vehicle, owned or operated by IU Health Bloomington. The undersigned fully understands the risks involved in being a passenger in a IU Health Bloomington
vehicle, including a BHAS emergency vehicle owned or operated by IU Health Bloomington, and assumes risk freely and voluntarily. This release indemnity and holds
harmless is given by the undersigned in consideration of IU Health Bloomington granting permission to ride in a IU Health Bloomington vehicle, including BHAS
emergency vehicle, owned or operated by IU Health Bloomington 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 IU Health Bloomington campus (including: in buildings or in vehicles owned and operated by IU
Health Bloomington). 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 In-service for Non-Hospital Personnel” under the student
web page.

I have read the guidelines and agree to adhere to the IU Health Bloomington Student Parking guidelines as outlined under the Student Website.

Personal Appearance & Dress Code
As an intern 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 an IU Health Bloomington 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 my internship 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 IU Health Bloomington operations and employees/human resources
       I will hold harmless IU Health Bloomington and its representatives from any damages obtained during student placement.
       I will not use tobacco products or smoke on the IU Health Bloomington 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 IU Health Bloomington” 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.

          I adhere to starting my internship on _______________________ and ending on _________________________

Signature______________________________________ Printed Name__________________________________ Date____________

                              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 at an IU Health Bloomington site. Therefore, the hospital is obligated to run a
criminal background check to ensure the safety of our patients, staff, and visitors. This page must be completed before you may begin
your internship.

Full Name: ____________________________________

Birth Date: __________________ Social Security #: _______-_____-__________

Please list your last two places of residence:

Street                              City              State       Zip

Street                              City              State       Zip

             Gender:                               Race/Ethnic
                 Male                             Identification:
                 Female                               Hispanic or                              Asian/Pacific
                                                          Latino                                  Islander
                                                       White                                    American Indian
                                                       Black or African                          or Alaska Native
                                                          American                               Two or more

             Authorization for Procural of a Consumer Report by IU Health Bloomington
             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 IU Health Bloomington, Inc. I hereby authorize IU Health Bloomington, 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.

             Signature: ______________________________________________________________

             Printed Name:___________________________________                            Date: _____/_____/_____


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