Transcription of Application For Medical Student Rotation
1 YAKIMA REGIONAL Medical & CARDIAC CTR 110 South Ninth Avenue Yakima, WA 98902 Medical Staff Services: (509) 575-5138 YAKIMA valley memorial hospital 2811 Tieton Drive Yakima, WA 98902 Medical Staff Services: (509) 575-8121 Application For Medical Student Rotation (This form must be completed in full with all attachments provided) NAME IN FULL: DATE: Any Other Name Used in Professional Practice: Medical School Name/Address: Contact Phone: Local Yakima Office Practice/Group Name: Residence Address: Residence Phone: DOB: SS#: e-mail address: Status Requested: Observational Active (must have a clinical education agreement on file with each hospital ) Rotation Start Date: End Date: Yes No Description Attach verification that this Rotation is an approved Rotation by your Medical school Attach verification that this Rotation is covered by professional liability insurance issued by the Medical school.
2 Attach documentation that you have completed instruction in basic physical examination and a working knowledge of ward procedures. Attach documentation of compliance with Student immunization policy of your program. Attach documentation of completion of a program on universal precautions for handling blood, tissues, and body fluids. Attach a completed and signed Washington State Patrol Criminal Background form (section C/D) * Attach a signed copy of the conjoined safety review form. * Attach a signed copy of the Providence HIPAA compliance agreement. * * items provided with this Application . SIGNATURE OF Student :_____ DATE:_____ Completed App. Rec d: Contract verified?
3 : COMMENTS: To Credentials Committee:_____ To MEC:_____ H:/POLICIES/Students/ Medical Student App Yakima Regional Information: Yakima valley memorial hospital 477 Emergency # 8123 477 Code Red Report to person in charge of area Evacuation routes posted on all units Fire extinguishers and alarms on all units 8123 Code Red Report to person in charge of area Know where the fire extinguishers and pulls are located Know location of emergency power outlets477 Code 99 Cardiac/Resp.
4 Arrest 8123 Code 99 477 Code 0 Infant Card/Resp Arrest 8123 Code 99 477 Code 1 Infant/Child abduction 8123 Code Yellow 477 Mr. North + location Disorderly/Assistance Needed 8123 code 7 + location 477 D500 Disaster Alert 8123 Disaster Alert 477 Trauma Team 8123 477 + location Bomb Threat 8123 + location 477 Security Pager #102 in house or call the operator Call 0 to request Security escort 5825 (Fred Millius) Safety Hotline 477 take protective measures Earthquake Emergency generators will activate in 10 sec Power Failure Switchboard/security will notify all departments. Codes will be called by radio, telephone, and pocket pagers Communication Failure 477 + location (move to a safe location) Chemical spill Located in each Department MSDS material safety info.
5 Located in each Department R-escue A-larm C-ontain E-xtinguish ENVIRONMENT OF CARE ROLES & RESPONSIBILITIES As a member of the Medical Staff/AHP, my role and responsibilities are to assist hospital staff in safety management, security management, safe handling and disposal of hazardous materials, emergency management, fire prevention, and equipment management. I will notify hospital staff immediately when I note problems in any of these areas. Reviewed by:_____ Date:_____ Signature of applicant PRIVACY TRAINING CERTIFICATE Purpose: This form is used to certify completion of privacy training by a workforce member. Section A Workforce member trained (complete this section) Name: Department: Name: Dept #:Job Title: Social Security Number: Date privacy training completed: ____/____/_____ Reason for privacy training: Initial Privacy Training Annual Training Violation of Policy Change in Privacy Policy Change in Job Role Other:_____ SECTION B Workforce member s training acknowledgement.
6 I have completed training on our organization s privacy policies and procedures. I am aware that any violation of patient privacy or confidentiality should be reported to our Privacy Officer, our Compliance Officer, or the Corporate HIPAA Compliance Manager. I am aware that failure to maintain patient privacy and confidentiality may result in termination of my employment. Signature: Date: Print name: SIGNATURE OF PRIVACY INSTRUCTOR. I attest that the above information is correct. Signature: Date: Print name: Title.
