s:\lah credentials\student rotations\2013 packet clin rotation letter & application\packet rotation cover letter & application.docx

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23 févr. 2014 (il y a 3 années et 7 mois)

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February 23, 2014


RE: Request for Clinical Rotation at Centura Health


Dear Student
, Resident

or Program Coordinator
,


Thank you for your interest in
Centura Health

as a potential site for
performing a rotation.
Attached is
our

Rotation Application
Packet. All documentation in
dicated below must be received by

the
appropriate
Centura Health
Medical Staff Services
Department

at least

15 days
prior to
the
start of the requested
rotation

date.

Rotations canno
t begin until the application and
all supporting documentation have been received, reviewed and approved by
each facility’s respective

Chief Medical Officer.



I
t
is

the
student/resident’s

and/or program coordinator’s
responsibility to obtain all appropri
ate signatures and documentation

to support their application

as follows:



a.

Legible government
-
issued identification such as a driver’s license or passport. (For hospitals that issue a temporary ID
badge for their rotations, students will be requested to
present an actual physical copy for verification.)

b.

Current Basic Life Support (BLS) certification or other certification as required for role.

c.

Occupational Health and Safety Administration (OSHA) training for infection control, fire safety, and environmen
t of
care
or

successful completion of the OSHA quiz (attached in Appendix A), if attestation letter does not verify OSHA
training.

d.

Tuberculosis (TB) testing, influenza vaccination (or valid signed medical exemption), and other immunizations as may
be required by the Centura Health’s hospital’s respective occupational health department. Influenza vaccinations or
valid medical exemptio
ns are required for any student rotation scheduled from September 1
st

through March 31
st

of
the following year in accordance to the Centura Health Influenza Policy. Students and residents will be required to
pursue vaccination at their own costs outside o
f Centura Health.

e.

Letter of good standing from the academic institution to include an attestation or actual copies of any criminal
background check conducted by the academic institution prior to the request for rotation
.

The letter of good standing
can be
accepted in lieu of an actual training program director signature on the Rotation Application.

f.

For residents, current Colorado training license number on application or actual copy of
training
license
.

g.

Where facility requires, academic course guidelines

h.

The signature of an identified Medical Staff Sponsor and/or Teaching Attending with appropriate privileges at the
Centura Health Hospital where the rotation is taking place. It is the clinical student/resident/academic institution’s
responsibility to have

made appropriate arrangements for supervision/sponsorship with a Medical Staff Preceptor or
Teaching Attending.

i.

Meditech Subscriber Agreement, if the rotation is greater than twenty
-
one (21) days in length.

(Signature page only is
preferred.)


Please ch
eck the respective hospital
that you are requesting a

rotation with below within the “Rotation Site” column, and return
the completed application to that hospital
.


Rotation Site

Centura Health Hospital

Phone

Fax


Avista Adventist Hospital

(303)673
-
1270

(303)673
-
1238


Porter Adventist Hospital

(303)778
-
2552

(303)778
-
5650


Littleton Adventist Hospital

(303)734
-
2064

(303)738
-
2599


Parker Adventist Hospital

(303)269
-
4042

(303)269
-
4041


Castle Rock Adventist Hospital

(720)255
-
2541

(720)255
-
2543


St.
Anthony’s Hospital

⠷(〩0㈱
-
ㄷ㈰

⠷(〩0㈱
-
ㄷㄱ


St. Anthony’s North

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-
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-
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⠳(㌩3㌰
-
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⠳(㌩3㔰
-
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St. Anthony’s Summit

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-
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-
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s:
\
lah credentials
\
student rotations
\
2013 packet clin rotation letter

& application
\
packet rotation cover letter & application.docx

Appendix I
-
ROTATION APPLICATION VERSION July 2013

Rotation Application

R
OTATION

TYPE
:



Resident


Medical Student


Physician Assistant
Student



Advance Practice Nurse
Student

APPLICANT

FULL LEGAL NAME



Address:


E
-
mail:


Phone #:


CO license # (where
applicable)
:


ACADEMIC INSTITUTION
NAME


Program Coordinator:


Program Coordinator
Contact Information
(Phone, Fax and E
-
mail):


Month/Year Graduating:


Current Program Year:


ROTATION


Dates (from/to)
:


Service
(specialty):


Medical Staff

Preceptor

and/or Teaching
Attending:


R
EQUIRED
S
IGNATURES
:

STUDENT: I have
received, read and understand

the policies addressing
clinical

rotations and agree to abide by these policies and
institutional guidelines and regula
tions
.
I acknowledge that I am responsible for producing adequate documentation to complete my
request for a rotation, and that failure to provide this information within a timely manner, will delay my rotation until suc
h time that
this documentation is
completed and submitted to the Medical Staff Services Department for review by the appropriate Hospital
representative.

Further, I acknowledge that I am responsible for completing any orientations that may be required of me in order to
begin my rotation a
nd that it is my responsibility to schedule this with the respective hospital I have been approved for.

_____________________________________________________
___________________
____________________
__
______________
_

Student
/Resident
Signature














Date

PROGRAM/SCHOOL:
(Letter of attestation can be accepted in lieu of signature.)
We acknowledge our responsibility for the conduct
and supervised care of our students/residents. We represent that the student/resident is in good standing, that we
have conducted
the appropriate criminal background check
s

and have provided OSHA training (unless OSHA quiz is completed
and successfully

by
student/resident). We have received a copy of your policies related to clinical rotations and agree to abide by th
em as well as any
other Hospital policy or guideli
ne that may be required of our students/residents.

_____________________________________________________
__________________
______________________
__
_______________

Program Director

Signature














Date

MEDICAL STAFF

PRECEPTOR

AND/OR TEACHING ATTENDING
: As a Medical Staff Member with appropriate clinical privileges

at the
Hospital(s) where the rotation has been approved and taking place
, I assume the role of preceptor an
d/or
teaching attendant for th
e
above
-
named applicant and agree to fulfill the responsibilities pursuant to the policies and procedures of
the Centura Health Hospital.


I acknowledge my responsibility to provide supervision to the above named individual and to report any concerns regar
ding the
rotation to the
academic institution and
to the
Medical Staff Services Department.


___________________________________________________________________________
____________________
_______________

Medical Staff Preceptor and/or Teaching Attending








Date


Appendix I
-
ROTATION APPLICATION VERSION July 2013


HIPAA
WAIVER, RELEASE & CO
NFIDENTIALITY STATEM
ENT


In consideration of participating in an educational experience at
Centura Health
, I indemnify
Centura
Health

and hold harmless its subsidiaries, representatives, agents and employees from liability, which
may result from my participation. I will not bring nor cause to be brought on my behalf any legal action
against
Centura Health
.


Recognizing that my educatio
nal experience provides access to a variety of information deemed strictly
confidential, I accept that it is the patient’s right to refuse permission for me to observe the delivery of
medical care or services delivered to that patient. I acknowledge my ob
ligation to maintain the
confidentiality of all information which I may possess as a result of the shadowing experience and that
disclosing such information is prohibited and unethical.


I acknowledge the risk that medical and surgical procedures may inclu
de graphic and shocking images
along with explicit discussion of the human body. I acknowledge and assume the risk that patients,
physicians, nurses and others involved with the delivery of medical care may unknowingly expose me to
infection and illness.


It is my voluntary decision to participate in this educational experience and agree to conduct myself in
an appropriate manner, to take direction from appropriate personnel and to dress in a professional
style.



_______________________________________


___________


_______________________


Student
/Resident

Signature














Date







Appendix I
-
ROTATION APPLICATION VERSION July 2013

OSHA INSERVICE

QUIZ

Students/Residents: If your academic institution has verified successful completion of
an

OSHA course

with us
, you do not need
to complete this form. However, please be advised that if you fail this quiz, you are required to complete a course through
your
academic institution, which may result in a delay in
the approval
your rotation.


__________________________
______________________________________________________________________

Signature












Printed Name








Date


True/False



1.

The Hepatitis B vaccine is recommended for healthcare workers who have a reasonable likelihood of coming in
contact with
blood/body fluids as part of their job tasks even if this may only happen occasionally.


2.

An exposure may occur if the practitioner gets a puncture wound with a contaminated sharp, has blood/body fluids
splashed into eyes, nose or mouth, or blood/body flui
ds come into contact with a cut, rash, or any open area on the
skin.


3.

In case of an exposure, the skin should be cleansed immediately with soap and water; eyes, nose or mouth should be
flushed with large amounts of water.


4.

If an exposure occurs, the pers
on should report it to his supervisor/employer and the unit’s Charge Nurse
immeTiaWely. Ini瑩al⁷orkup⁳houlT be in楴ia瑥T as⁳oon 慳 possib汥




A person who has an exposure should consult his/her personal physician regarding any follow up


6.

It is
important to use a two
-
handed technique when recapping needle


7.

A healthcare provider gets blood into an open cut from a 93 year old female patient; because of the low risk of HIV,
HBV, it is not necessary to report the incident as an exposure


8.

It is acce
ptable to pick up broken glass as long as you are wearing gloves


9.

It is NOT necessary to wash hands after a procedure if one has been wearing gloves


10.

The Center for Disease Control recommends that all surfaces of the healthcare worker’s hands be
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-
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wiWh a pa瑩enW.


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Personal scrub caps are to be covered with hospital provided caps when a person is at the sterile field.


12.

In the OR, protective eye wear such a masks with face shields, goggles, or glasses with side
-
shields, are to be worn
during surgical procedures except when looking through a microscope


13.

Contaminated gowns, masks, and gloves may be discarded in the dress
ing room


14.

If a person is using an alcohol
-
based hand scrub solution before a sterile procedure, it is NOT necessary for him/her to
prewash the hands and forearms with soap and water and dry before applying the solution


15.

If using an antimicrobial scrub
brush to scrub hands for a sterile procedure, AORN recommends that the sponge side
of the brush be used instead of the bristle side.



Appendix I
-
ROTATION APPLICATION VERSION July 2013

CENTURA INFORMATION TECHNOLOGY APPLICATIONS SUBSCRIBER AGREEMENT


To enhance our collaborative effort to provide high qu
ality and efficient health care to the communities we serve, the following
will help to identify expectations concerning the use of electronic patient care applications and technologies. This Agreem
ent is
designed to be comprehensive to avoid the need to

sign multiple agreements and to address security, privacy and
confidentiality issues. It covers all currently installed Centura clinical and business applications. It also covers wired
and
wireless networks, hardware such as computers and printers.


INTRODUCTION

To promote improved healthcare to the community, Centura Health Corporation (“Centura”) in collaboration with other
healthcare community members, has established an internet Portal through which authorized physicians and clinicians may
access
clinical, operational and financial applications, content and links. These applications include, but are not limited to
Portal, PowerChart, the Clinical Information System, RIS/PACS and any like or similar electronic applications, hardware or
systems (“Ap
plications”). The terms of participation in the use of these Applications are set forth in this Subscriber
Agreement (“Agreement”).

1.

LICENSE GRANT

Centura grants you a non
-
exclusive, non
-
assignable license to use these Applications, and to use future upda
tes, modifications,
enhancements, and new products developed, owned or licensed by Centura or other third parties that are generally available in

support of the these Applications. The terms of this Agreement apply only to all the Applications. At this ti
me you will not be
charged a fee for use of these. In the future and after written notice to you, Centura may charge a fee for use of any portio
n or
all of the current Applications, or any future updates, modifications, enhancements, and new products. The
Applications are
licensed by third parties to Centura, and the terms and conditions of the specific licenses granted to Centura control the
Agreement and use of the Applications. Centura cannot provide any greater scope of license than that provided by th
e third
party licensor, and the terms and conditions of the underlying third party license control and supercede the Agreement at all

times. By signing below and using the Applications, you agree to use the Applications only for their intended purposes an
d in a
manner that will guard against misuse of confidential patient information. For example, you should not risk the confidential
ity
of patient information by allowing others to use your electronic devices containing clinical information or risk placing

the clinical
information contained in the Applications in an incorrect patient chart or record.


2.

USER SUPPORT OF THE APPLICATIONS

Centura and its hospitals will support the use of the Applications. This support includes continuous 24 hour telephone hel
pdesk
to assist in problems related to access and use. Support of the computer workstation, connectivity to the Internet, printers
,
Internet browser applications and other applications on the user’s computer or device are not supported by Centura.


3.

PROPERTY RIGHTS

The Applications and all other related documentation are proprietary products of Centura and its licensors, subject to copyri
ght,
trademark, and other intellectual property laws. Centura grants no transfer of ownership or license in the pro
prietary products
of Centura and its licensors other than that specifically set forth in this Agreement. Notwithstanding the license grant, Cen
tura
and its licensors retain all of their ownership and license rights in licensors. Nothing in this Agreement g
rants you any rights,
license or interest with respect to the source code of these applications. You shall not copy, duplicate, reverse engineer, r
everse
compile, disassemble, record, or otherwise reproduce any part of these Applications, nor attempt to do

any of the foregoing.
You shall not use these Applications for any purpose except for use and operation for ordinary business purposes within the
terms of this Agreement. All records of the transmission of any data as the result of your use of these Appli
cations are the
property of Centura and shall remain the property of Centura, even if this Agreement is terminated by either party. Databases

accessed through these Applications are the property of the applicable content owner and applicable laws protects
ownership
and related rights in the databases. The license granted under this Agreement give you no right to such content and requires
that you use the Applications only as intended and within the scope of such grant.


4.

COPIES

You shall not make copies of t
hese Applications. Upon termination of this Agreement, you will cease use of these Applications,
and delete the data from your file structures. You will not make copies of any user guides and instructional materials and ot
her
related documentation except
as necessary for use of these Applications within the terms of this Agreement. All copies of user

Appendix I
-
ROTATION APPLICATION VERSION July 2013

guides or instructional materials and other related documentation are strictly proprietary and confidential and shall not be
copied, reproduced or distributed

to any non
-
Centura facility or employee and shall be returned to Centura upon termination of
this Agreement.


5.

NETWORK SOFTWARE COPYRIGHT NOTICES

You agree not to remove, alter, reproduce, or destroy any proprietary, trademark or copyright markings or noti
ces placed upon
or contained within these Applications and any user guides or instructional materials, and other related documentation.


6.

TRADEMARKS

You shall acquire no rights of any kind in or to any trademark, trade name, logo or product designation used

in connection
with these Applications. You shall cease to use the markings, or any similar marking, in any manner on the expiration or othe
r
termination of this Agreement.

7.

NO WARRANTY

These Applications are licensed to you “AS IS” and without any warranti
es expressed, implied or statutory. Centura and its
licensors do not warrant the accuracy, completeness, noninfringement, title, merchantability or fitness for a particular
purpose of these Applications or their use. You recognize and acknowledge that the
se applications are used as tools to
facilitate clinical care and are not intended to be relied upon as a substitute for professional, clinical judgment.

8.

LIMITATION OF LIABILITY

Centura and its licensors acknowledge that this Agreement provides you the
ability to access information, whether clinical or
other, and that Centura and its licensors will not be liable to you or to other third parties for indirect, direct, incidenta
l,
consequential, special, punitive, or exemplary damages of any kind as a resul
t of incorrect clinical decision or adverse patient
outcome and any breach of any term of this Agreement (including misuse of any application or careless use of electronic devic
es
such as loss of such devices) or with respect to any and all claims arising
from or related to the subject matter of this Agreement
whether in contract, tort, or otherwise, and Centura’s and its licensors’ aggregate liability arising out of or related to th
is
agreement shall not exceed the total amounts payable by you hereunder, s
ubject to applicable state law. Centura has no
responsibility for the content, accuracy, or interpretation of any communication facilitated by use of these Applications or
information databases available through these Applications. Centura has no responsib
ility for any action taken by you, including
but not limited to any health care administered by you in reliance of any communication facilitated by use of these Applicati
ons
or information databases available through these applications. Centura has no resp
onsibility for unauthorized access to or use
of these Applications from your electronic devices. Centura has no responsibility for unauthorized disclosure or patient
information by anyone accessing or using your computer(s) or facsimile machine(s). Centura

has no responsibility for compiling
storing, or maintaining patient files of any kind. Centura has no responsibility for obtaining proper patient consents, relea
ses
and/or authorizations for you to use these Applications to facilitate electronic communica
tion of confidential patient
information.


9.

APPLICATIONS ACCESS AND UTILIZATION

You are responsible for providing access to the Internet 24 hours per day, seven days per week. Centura

shall have no liability
for the performance of such connection to access to these Applications. You agree to follow the instructions and standards
for use of these Applications set forth in the learning sessions and documentation and other related documen
tation.

10.

LENGTH OF AGREEMENT

This is a month
-
to month Agreement. Either party may terminate this Agreement for any reason at the end of any month by
notifying the other party in writing by U.S. Mail, courier, or facsimile, or electronic mail. Centura has th
e right to terminate
your access to these Applications immediately if you or anyone using your computer(s), Internet connection or facsimile
machine(s) breaches or otherwise fails to honor any obligation hereunder, or if an entity’s sponsorship of you term
inates.

11.

AUTHORIZED COMMUNICATION

You authorize communication of patient identifiable information through use of these Applications from and with any and all
individuals and entities that are authorized to use these Applications, and further authorize inclu
sion of your name or entity in
such individuals’ and entities’ subdirectories.
You acknowledge that these Applications are intended for communication
between the sponsoring hospital or facility and its subscribers; that any unintended or unauthorized use
by you to
communicate confidential patient information may compromise the security of the patient information; and that you will be
responsible and liable for any such unauthorized disclosure.




Appendix I
-
ROTATION APPLICATION VERSION July 2013

12.

APPLIED TO ALL USERS

The terms of this Agreement apply to eac
h person or entity who accesses these applications on your computer(s) or facsimile
machine(s). You shall have responsibility to ensure compliance with the terms of this Agreement by each such user.

13.

USER AUTHENTICATION

As a user of these Applications, you

will enter the Applications by identifying yourself. Currently, you will have a personal user
identification name and password to enter these Applications. Your personal user identification and password may not be
shared with any other user. You shall ta
ke all reasonable steps necessary to safeguard all assigned passwords including, but not
limited to, establishing and enforcing reasonable procedures to ensure that all persons who are assigned passwords maintain
their confidentiality and otherwise limit t
he use of these Applications to prevent unauthorized access and use. In the future,
you may be asked to authenticate your identification through other means. These may include biometric identification such as

fingerprint, recognition and random password
generation keyrings.


14.

PATIENT INFORMATION

All patient information accessed via these Applications is absolutely confidential and is never to be viewed by or disclosed
to
anyone other than authorized persons who have a legitimate need to know the informatio
n in accordance with applicable law.
Patient information is legally and ethically considered privileged information and is protected by law. You agree to indemni
fy
and hold Centura harmless against any claim or penalty arising as a result of your intentio
nal, reckless or willful misuse of
protected health care information or your failure to comply with this Agreement.


15.

ASSIGNMENT

Centura may assign part of any rights, duties, and obligations under this Agreement to any Centura affiliate. This Agreement
is
personal to you, and you may not assign your right or obligations to anyone.


16.

MODIFICATION

Centura reserves the right to modify the terms and conditions of the use of these Applications, including, if required by
federal law, charges, and to introduce new
terms, conditions, and charges. Such modifications and introduction of new
terms, conditions, and charges shall become effective only after notice to you. Notice may be by U.S. mail, courier, facsimil
e,
or electronic mail. You agree that your continued us
e of these Applications after the publication of the notice shall
conclusively be deemed to be the acceptance of the modified terms and conditions.

17.

NO OBLIGATION TO REFER

The intent and purpose of this Agreement is to promote and facilitate patient care th
rough improved access to timely and
comprehensive patient data needed for core delivery of health care. Nothing contained in this Agreement should be construed
as an inducement or reward for patient referral. On the contrary, the subscriber under this Ag
reement has no obligation to
refer patients to hospitals of Centura.


18.

SEVERABILITY

If any provision of this Agreement is determined to be invalid or unenforceable, such invalidity shall not affect other provi
sion of
this Agreement.


19.

LIABILITY

You agree
that you shall be liable for any and all claims, costs, and expenses, arising from and out of your alleged negligent
act(s) or omission(s) and those of your agents or employees, in the performance of your obligations under this Agreement.


Centura shall be

liable for any and all claims, costs, and expenses, arising from and out of an alleged negligent act(s) or
omission(s) of Centura, its agents or employees, in the performance of its obligations under this Agreement.


20.


COMPLIANCE WITH CENTURA HEALTH POLICI
ES AND PROCEDURES

You agree to use the software in a manner consistent with all applicable provisions of law and other rules and regulations of

governmental authorities regarding the licensure, regulation and accreditation of physicians and hospitals and in compliance
with
all applicable policies, rules and regulations of Centura Health, including but not limited to the “Meditech Clinical
Workstations Policy,” as they may be amended from time to time.


21.

COMPLIANCE WITH FEDERAL AND STATE CONFIDENTIALITY REQUIREMENTS


Appendix I
-
ROTATION APPLICATION VERSION July 2013

You acknow
ledge and agree that all patient records shall be subject to the confidentiality and disclosure provisions of federal
and state laws, regulations, and ordinances and agree to maintain the confidentiality of all such records in accordance with
such
laws. T
his provision shall survive the termination of this Agreement.

22.

GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the State of Colorado.


23.

ENTIRE AGREEMENT

This Agreement and its attachments constitute the entire
agreement between the parties with respect to the subject matter
hereof and supersedes all prior agreements or understandings of the parties relating thereto.


24.

COUNTERPARTS

This Agreement may be signed in any number of counterparts, each of which shall be
an original, with the same effect as if the
signature thereto and hereto were upon the same instrument. Signature of this Agreement may be communicated by facsimile
transmission. If executed in counterparts, the Agreement shall be effective as if simultane
ously executes.

25. MAINTENANCE AND SUPPORT

You understand and acknowledge that support services provided by Centura Health personnel or any IT support personnel may
conceivably result in certain programs or functions of your personal computer not function
ing properly, and you understand
and acknowledge that this result may occur through no fault of the personnel of Centura Health. Knowing and understanding
the risk of accepting the support services of personnel of Centura Health, you assume all responsibil
ity and risk for any damage
to my personal computer that may result from those services. Furthermore, you agree in advance to release, waive, forever
discharge, and covenant not to sue Centura Health, any of its employees, officers, or agents from and agai
nst any and all liability
for any harm, injury, damage, claims, demands, actions, causes of action, costs, and expenses of any nature that may result
from support services you accept for your personal computer.


26. ELECTRONIC SIGNATURE

The undersigned rep
resents and warrants that he/she is the only individual who will use the designated account, personal
identification number, and/or password to view patient information, enter orders or clinical information, or otherwise sign
documents using an electronic
signature.


In signing this subscriber agreement, you acknowledge and represent that you have fully informed yourself of the content of t
he
foregoing waiver of liability by reading it before you sign it, and you understand that you sign this document as your own fr
ee
act and deed; no oral representations, statements, or inducements, apart from the foregoing written statement, have been
made.


Practice Name:





Address:





City:




State:




Zip Code:





Phone Number:




Fax Number:





Name and Title:




CO License

#:





Signature:



Today’s Date:



Please return a signed copy of this page only when submitting your rotation application
,

if your rotation is greater than
twenty
-
one
(21)
days in length and where facility permits access to the Electronic Health Record
(EHR).