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Parkview Job Shadow Passport Instructions: Complete all sections of the Student Passport. All paperwork can be submitted via email to [email protected]. Applicants that do not completely finish the forms will be asked to finish the paperwork before being accepted. Returning students only need to submit the front page of the Job Shadow Passport Student Services should receive completed forms a minimum of two weeks prior to the scheduled start date.

Parkview Health | Student Services | 1919 W. Cook Road | Fort Wayne, Indiana 46818

Revised October 2019

mailto:[email protected]

Job Shadowing Request & Information Form

This section is to be completed by the individual requesting a Job Shadow.

Is this Job Shadow to help you explore a career you are interested in going to school for?

□ YES Continue filling out this form. □ NO STOP! Job Shadowing must be for career exploration to be permitted. Vendors should contact Parkview Supply Chain for Vendor observation process.

Name (please print)

Phone

Email

Home Address

Date of Birth

Have you Job Shadowed at Parkview Health before?

□ NO □ YES

Specify the date(s) & location(s): ________________________________

Current School (if applicable)

Career Interest(s)

I would like to Job Shadow on the following date: _________________(mm/dd/yy)

□ 4 hours: 8am-12pm □ 4 hours: 12pm-4pm □ 8 hours: 8am-4pm

□ Special Evening/ Weekend hours:______________________________

If the above date/time is not available, my second date choice is: _____________________ (mm/dd/yy)



If the above date/time is not available, my third date choice is: _____________________ (mm/dd/yy)



Name of Emergency Contact

Relationship to Student

Cell/ Home Phone Number of Emergency Contact

Work Phone Number of Emergency Contact (if applicable)

Refer to the JOB SHADOWING Selection Chart Below to answer the following questions.

The PROFESSIONAL I would like to Job Shadow with is: I would like to Job Shadow at the following LOCATION:

Is there a SPECIFIC person you would like to be assigned to? Indicate name.

I acknowledge by my signature that I have read and studied the information contained in this Student

Passport including the Job Shadowing Day, Privacy and Safety Guidelines.

Signature (Parent if under 18) _____________________________________ Date _____________ Please submit completed forms to Parkview Student Services at [email protected]


Parkview Clinical Opportunities

Child Life Specialist

Parkview Regional Medical Center

Doctor or Physician

Parkview Physicians Group Office

Emergency Care Technician

Parkview Randallia Parkview Regional Medical Center Parkview Huntington Parkview LaGrange Parkview Noble Parkview Whitley Parkview Dekalb

EMT/ Paramedic

Parkview Huntington Parkview LaGrange Parkview Noble Parkview Whitley Parkview Dekalb

Cardiac Pulmonary Rehab


Exercise Specialist - Fitness

Parkview Health & Fitness Center Parkview Sports Medicine

Laboratory Technician

Parkview Randallia Parkview Regional Medical Center Parkview Huntington Parkview LaGrange Parkview Noble Parkview Wabash Parkview Whitley

Medical Assistant

Parkview Occupational Health Parkview Physicians Group Offices

Medical Coder

Parkview Randallia

Mental Health Counselor

Parkview Behavioral Health*

Occupational Therapist

Parkview Randallia Parkview Regional Medical Center Parkview Ortho Parkview Huntington Parkview LaGrange Parkview Noble Parkview Wabash Parkview Whitley Parkview Home Health & Hospice*

Occupational Therapy Assistant

Parkview Regional Medical Center Parkview Ortho Parkview Huntington Parkview LaGrange Parkview Noble Parkview Whitley Parkview Outpatient Rehab Randallia Parkview Outpatient Rehab PRMC

Patient Care Technician

Parkview Clinical Nursing Opportunities

Cardiac Cath Lab


Cardiac Intensive Care


Cardiac Unit


Constant Care Unit

Parkview Randallia Parkview Huntington Parkview LaGrange Parkview Noble Parkview Whitley Parkview Dekalb

Diagnostic Imaging or X-Ray


Emergency Department**

Parkview Randallia Parkview Regional Medical Center Parkview Huntington Parkview LaGrange Parkview Noble Parkview Whitley

Education

Parkview Randallia Parkview Regional Medical Center Parkview Ortho Parkview Behavioral Health* Parkview Huntington Parkview LaGrange Parkview Noble Parkview Whitley Parkview Home Health & Hospice*

Extended or Long Term Care

Parkview Randallia

Home Health & Hospice

Parkview Home Health & Hospice*

Nurse Assistant/ CNA

Parkview Randallia Parkview Regional Medical Center Parkview Ortho Parkview Huntington Parkview LaGrange Parkview Noble Parkview Whitley

Medical Unit


Medical Surgical Combined Unit

Parkview Randallia Parkview Huntington Parkview LaGrange Parkview Noble Parkview Whitley Parkview Dekalb

Mental Health

Parkview Behavioral Health*

Parkview Non-Clinical Opportunities

Administration Director

All Locations

Manager

All Locations

Chaplain

Parkview Randallia Parkview Regional Medical Center Parkview Behavioral Health*

Dietitian

Parkview Regional Medical Center Parkview Behavioral Health* Parkview Huntington Parkview LaGrange Parkview Noble Parkview Randallia Parkview Whitley

Finance

Parkview Corporate Office Parkview Randallia Parkview Regional Medical Center Parkview Huntington Parkview LaGrange Parkview Noble Parkview Wabash Parkview Whitley

Human Resources Professions

Parkview Corporate Office Parkview Education Center Parkview Randallia Parkview Regional Medical Center Parkview Huntington Parkview LaGrange Parkview Noble Parkview Wabash Parkview Whitley

IS Analyst

Parkview Business and Technology Center Parkview Corporate Office Parkview Randallia Parkview Regional Medical Center Parkview Huntington Parkview LaGrange Parkview Noble Parkview Wabash Parkview Whitley

Legal

Parkview Corporate Office

Marketing/ Communication Relations Specialists

Parkview Corporate Office

Security Officer


Parkview Randallia Parkview Regional Medical Center

Pharmacist & Pharmacy Technician


Physical Therapist & Assistant

Parkview Randallia Parkview Regional Medical Center Parkview Ortho Parkview Huntington Parkview LaGrange Parkview Noble Parkview Wabash Parkview Whitley Parkview Home Health & Hospice Parkview Outpatient Rehab Randallia Parkview Outpatient Rehab PRMC Parkview Sports Medicine Parkview Dekalb

Physician Assistant

Parkview Physicians Group Office

Radiologic Technology or Diagnostic Imaging

Parkview Randallia Parkview Regional Medical Center Parkview Huntington Parkview LaGrange Parkview Noble Parkview Wabash Parkview Whitley Parkview Physicians Group Office Parkview Dekalb

Respiratory Therapist


Speech Language Pathologist


Surgical Technician

Parkview Ortho

Unit Assistant


Neonatal Intensive Care+


Neuro Unit


Obstetrics Intensive Care

Parkview Regional Medical Center Parkview LaGrange Parkview Noble Parkview Whitley

Occupational Health

Parkview Occupational Health

Oncology


Pediatrics+

Parkview Regional Medical Center Parkview Physicians Group Office

Operating Room

Parkview Ortho Parkview Huntington Parkview LaGrange Parkview Noble Parkview Whitley

Physician Office or Clinic

Parkview Occupational Health Parkview Physicians Group Office

Rehab Unit

Parkview Randallia

Surgery Admission & Recovery


Surgical Intensive Care Unit


Surgical Unit

Parkview Randallia Parkview Regional Medical Center

Wound Care

Parkview Regional Medical Center Parkview Randallia Parkview Dekalb

Social Work

Parkview Behavioral Health* Parkview Randallia Parkview Regional Medical Center Parkview Huntington Parkview LaGrange Parkview Noble Parkview Wabash Parkview Whitley

Key

*It is required that you be at least 18 to shadow at Parkview Behavioral Health & Parkview Home Health & Hospice

**It is required that you be college age or older and obtaining a degree in a Health Care Profession to shadow in the Emergency Department

+You must be at least 18 to shadow in Neonatal Intensive Care & Pediatrics Units

Instructions for Completing the Student Observation Agreement

Please complete the Student Observation

Agreement by including the following details on

the form:

1.Name 2. Address 3.Department Name and Parkview Location Please include both the name of the department and the specific name of the Parkview facility.

4.Date Job Shadowing begins 5.Date after Job Shadow (allows for 24-hour period).

6.Signature 7.Initials 8.Date 9.Birthdate 10.Parent’s signature if under age 18.

Please submit completed forms to Parkview Student Services:

Email: [email protected]

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STUDENT OBSERVATION AGREEMENT

BY AND BETWEEN

Parkview Health System, Inc. d/b/a Parkview Physicians’ Group, Parkview Occupational

Health Centers, Inc., Parkview Hospital, Inc. d/b/a Parkview Regional Medical Center and Parkview

Hospital Randallia, Huntington Memorial Hospital, Inc. d/b/a Parkview Huntington Hospital, Whitley

Memorial Hospital, Inc. d/b/a Parkview Whitley Hospital, Community Hospital of Noble County, Inc.

d/b/a Parkview Noble Hospital, Community Hospital of LaGrange County, Inc. d/b/a Parkview

LaGrange Hospital, Parkview Wabash Hospital, Inc., DeKalb Memorial Hospital Inc. d/b/a Parkview

DeKalb Hospital, The Orthopaedic Hospital at Parkview North, LLC, Midwest Community Health

Associates, Inc., (collectively or individually “The Facility”)

AND ________________________________, whose address is _________________________________

(Student/Individual)

WHEREAS, the Facility is organized for the purpose of operating a health care facility,

including the operation of a ______________________________ department; and,

In consideration of the mutual understanding that the student observation experience will be

offered to allow the Student/Individual to gain in-depth knowledge about a specific health career and

that the experience will consist of observational experiences only:

Section 1. Relationship of Parties Observation Student/Individual shall not be deemed to be an employee or agent of Facility or of Parkview Health, Inc. ("PH"). Section 2. Responsibilities of the Student/Individual With respect to the Program identified in this

Agreement, the Student/Individual agrees that he/she:

a. Has read and understands the accompanying Guide for Shadowing Experience

including information on Occupational Health and Safety Administration ("OSHA") Blood-Borne Pathogen Regulations, Hazardous Materials, Fire Safety/Codes, Infection Control and Infectious Waste;

b. May be required to wear gloves, masks/face shields or other protective clothing; c. Submits a signed "Confidentiality Agreement" to the Facility representative; agrees to

dress in the appropriate manner for the professional environment (no jeans, shorts or sandals);

d. Will act in a professional manner in their observational role while at the Facility. The student will be solely responsible for expenses incurred during the observation educational experience regardless of whether such expenses are:

a. For health care services provided by Facility, or b. Otherwise incurred in connection with the observation educational experience.

Section 3. Responsibilities of the Facility Representative

With respect to the Program identified in this Agreement, the Facility representative shall:

a. Serve as a health care representative which Observation Student(s)/Individual(s) may be

allowed to watch in selected roles, and assure that the experience is limited to only observation activities;

b. Retain ultimate responsibility for patient care, ensuring that Facility staff direct or supervise all aspects of patient care.

Section 4. Term It is understood and agreed that the term of this Agreement shall be from _______________ to _______________.

The parties have caused this agreement to be executed and limited to the later day and year written below.

“FACILITY” “STUDENT/INDIVIDUAL”

Parkview Health System, Inc. d/b/a Parkview

Physicians’ Group, Parkview Occupational Health

Centers, Inc., Parkview Hospital, Inc. d/b/a Parkview

Regional Medical Center and Parkview Hospital

Randallia, Huntington Memorial Hospital, Inc. d/b/a

Parkview Huntington Hospital, Whitley Memorial

Hospital, Inc. d/b/a Parkview Whitley Hospital,

Community Hospital of Noble County, Inc. d/b/a

Parkview Noble Hospital, Community Hospital of

LaGrange County, Inc. d/b/a Parkview LaGrange

Hospital, Parkview Wabash Hospital, Inc., DeKalb

Memorial Hospital Inc. d/b/a Parkview DeKalb

Hospital, The Orthopaedic Hospital at Parkview

North, LLC, Midwest Community Health Associates,

Inc., (collectively or individually “The Facility”)

By: ____________________________ By: ___________________________ Its: ____________________________ Its: ____________________________ Date: __________________________ Date: __________________________

Birthdate: ______/______/_______

By: ______________________________ Parent’s signature if student/individual is under age of 18.

PARKVIEW HEALTH

CONFIDENTIALITY AGREEMENT

I understand that in the performance of my duties as an affiliating student or faculty member of

affiliating school that during my participation in the clinical education program at Parkview Health

System, Inc. (“Facility”) I may have access to and may be involved in the processing of verbal,

written, computer generated, computer accessed, filmed, and/or recorded information related to

patients, physicians, employees and business information, all identified as “Confidential Information”,

as defined by the Parkview Health Confidentiality Policy. I understand that I am required to protect

and maintain the confidentiality of this Confidential Information at all times.

I acknowledge that if my position requires application of an electronic signature code, it is the

equivalent of my legal handwritten signature. I understand that if I disregard the confidentiality of my

electronic signature code, use the code of another person, or fail to comply with these confidentiality

requirements, I will be committing an illegal and/or unprofessional act.

I understand that a violation of these confidentiality considerations may result in disciplinary action, up

to and including termination of my participation in the clinical education program at Facility or legal

action.

I certify by my signature that I have knowledge of the provisions of the Parkview Health Confidentiality

Policy. I agree to adhere to and uphold Parkview Confidential Information.

Name: ____________________________________________________________________

(please print)

Signature: ___________________________________________________ Date: ________________

Parent Signature: _____________________________________________ Date: ________________

(if under age 18)

Email Address: ____________________________________________________________

HEALTH HISTORY

Full Name Including Middle Initial (please print)

Phone Number

Email Address

Home Address

Date of Birth College/University/School (If Attending)

Vaccinations:

- Measles/Mumps/Rubella vaccine: Date #1_______________ Date #2_______________ Date #3________________

Or

Rubella AB titer: Date ___________________

Rubella measles AB titer: Date ___________________

Mumps AB titer: Date ___________________

- Tetanus Diphtheria: Date ___________________

- Annual influenza vaccine - for the current flu season: (season runs from October 1 thru April

30 each year)

Date #1__________________ Or ☐ Did not receive vaccine

- Hepatitis B Vaccine: Date #1_______________ Date #2_______________ Date #3________________

Titer (date drawn): ____________

- Did student have the chickenpox? ☐ Yes ☐ No (If no please include vaccination dates below)

Chicken Pox (Varicella) vaccine: Date #1 ______________ Date: #2 ______________

Titer (date drawn): _____________

Additional Comments regarding vaccinations:

TB FORM

TB (Tuberculosis) TEST

TB Test (Mantoux, PPD, TST or Quantiferon – TB Gold):

Date __________________________ (within last 12 mo.) If positive reactor, a Chest X-ray is required: Date __________________________ Please attach copy of X-ray results

TB Tests can be obtained at area Parkview Occupational Health Centers, other urgent care centers, clinics, or private physician offices for a cost of approximately $20-25. Parkview does not cover this expense for students or observers at our facilities. Please present this form to the agency when obtaining a TB Test. A return visit to the agency may be required 48-72 hours after the TB skin test is administered to have the results read.

I hereby affirm that the health vaccination history and TB test information given on this form is accurate and complete.

____________________________________________________________________________________

Signature (Applicant or Parent) Date

Healthcare Personnel, Volunteers, and Students

Influenza Vaccination Status

All employees, licensed independent practitioners, volunteers, students and job shadow participants age 18 and older are required to complete this form.

Full Name Including Middle Initial (please print) Date

Department of Shadow

Location of Shadow

Have/will you work at this healthcare facility for at least one day between October 1 and March 31?

□ No; Stop Here □ Yes; Continue

Have/will you work in the Inpatient Rehab department for at least one day between October 1 and March 31?

□ No □ Yes

Have you received a flu vaccination at any Parkview Occupational Health site this season

□ No; Continue □ Yes; Choose one and stop here:

□ Allen County Occupational Health

□ PHH Occupational Health

□ PLH Occupational Health

□ PNH Occupational Health

□ PWH Occupational Health

Have you received a flu vaccination at a Parkview facility since it became available this season?

□ Yes; Continue □ No; Choose one and stop here:

□ Other Hospital

□ Primary Physician

□ Retail Pharmacy

□ Other Employment

□ Other Clinic

□ Other Source

Have you declined to receive the influenza vaccine this season?

□ No □ Yes, Please Explain:

Please Keep the Following Section for Personal Review

Keep this section available for quick reference and bring with your email confirmation on your Job Shadowing Day.

Job Shadowing Day, Privacy & Safety Guidelines DRESS CODE

Our patients and families deserve and expect professional appearance from everyone

they encounter at Parkview. Make sure your clothing is well-selected, clean and wrinkle-

free so you look your personal best.

Dress code for the day is “BUSINESS CASUAL.” Examples may include clothing such as slacks, khakis, sweaters, collared or polo shirts, and other items that would be worn in professional settings or places of worship.

You MAY NOT wear jeans, shorts, sweatshirts/pants, clothing with holes, or any clothing that is inappropriate in a professional work environment.

Footwear must be closed-toe, with safe non-skid soles. No sandals or flip-flops. Athletic shoes are OK.

Please avoid displaying extremes in clothing, hair styles, jewelry, visible tattoos, and body piercings.

CHECKING IN

You MUST have your PRINTED email confirmation form when you arrive in order to complete your job shadow.

If you do not have your confirmation form, you will NOT be allowed to complete your job shadow.

When you arrive to your facility, please report immediately to the Information Desk in the front lobby and present your confirmation form.

SHADOW DAY SUGGESTIONS

It is highly recommended that you eat a meal prior to arriving. You may be exposed to situations that can make you feel queasy. A good meal will help prevent this! Additional food items and beverages are available for your purchase in designated dining and vending areas at each facility.

If you feel uncomfortable, dizzy or ill at any time, please let your staff member know immediately. Do not hesitate. We understand that new experiences in the hospital can be overwhelming at times.

Stay attentive and engaged in your observation and maintain professional behavior at all times. You are welcome to ask our staff questions as appropriate. Please remember that your experience is observation only, and you will not be participating in hands-on activities.

FOR ADDITIONAL ASSISTANCE

If you need additional assistance, please contact [email protected].


Parkview Mission, Vision, & Values MISSION

Parkview Health will improve the health and well-being of our communities.

VISION

Parkview Health will be your partner in health.

VALUES

Trust - We have mutual respect and confidence in others.

Quality - We put trusted care into action through technology, education, and best practices in medicine.

Flexibility - We accept change in innovative and proactive ways.

Teamwork - Working together, we actively and respectfully listen to each other’s’ ideas. We communicate openly, honestly, and constructively.

Stewardship - We manage the care of our patients as if they were members of our family and we manage financial and material resources as if they were our own.

Confidentiality - What does it mean? Confidentiality means “keeping information private.” In a hospital or healthcare setting, all patient

information is considered confidential. We follow HIPAA guidelines. Any information about patients that is

spoken, on paper, or on computer is to be kept private. You cannot tell your family, friends, or anyone else

(who is not taking care of the patient) about this information.

Examples of confidential information include:

- Name

- Address

- Age

- Social Security Number

- Whether Someone is in The Hospital

- Diagnosis or The Reason Why Someone is in The Hospital

- Treatments and Medications

- Past Health Conditions

If you share any of these types of information with people who do not need to know, you have broken confidentiality and you have broken the law! This can lead to fines and potential jail time.

In addition to patient information, confidentiality must also include privacy of:

- Business-Related Information

- Fellow Employee Personal and Employment Information

Please agree to keep patient information confidential and remember… “A slip of the lip-pa violates HIPAA.”

Fire and Security Information All fire information is available in your departments Emergency Preparedness Manual. Please check with your department Manager/Supervisor as to your responsibilities in a Code Red situation.

FIRE

- Know where the fire pull stations are in your area.

- Know where the fire extinguisher is in your area.

- Know what the evacuation plan is for your area.

- If you see or suspect a fire remember: RACE and PASS

R Rescue P Pull

A Alert (Dial 1-911) A Aim

C Contain S Squeeze

E Extinguish S Sweep

RACE stands for the four steps to follow in the event of a fire: - Remove/ rescue persons from immediate danger. - Activate the alarm closest to the fir area. Alert persons in the immediate area by

announcing the phrase “Code Red” several times. - Contain fire by closing doors and windows where the fire is located. - Extinguish the fire by using the proper type of fire extinguisher, when appropriate.

PASS stands for the proper way to use a fire extinguisher: - Pull the pin. - Aim at the base of the flame. - Squeeze the handle. - Sweep from side to side.

Overhead Announcement Plain Language Announcement

Fire Alert

- Code Red

Emergency Tone + “Fire Alert” + location of fire

Security Alert

- Code Green (Bomb Threat)

- Code Gray (Violent Behavior)

- Active Shooter

- Code Pink (Infant/Child Abduction)

- Emergency Tone + “Security Alert” + “suspicious package-unknown area” or “Suspicious package-security needed to (area)”

- Emergency Tone + “Security Alert” “Security needed in (area)” - Emergency Tone + “Security Alert” “Active Shooter (area)” - Emergency Tone + “Security Alert” “Missing Infant/Child” or “Infant Child

abduction”

Weather Alert

- Code White

Emergency Tone + “Weather Alert” + specific weather event o “Tornado Warning” o “Thunderstorm Warning”

Emergency Alert - Code Blue (Cardiac Arrest) - Rapid Response - Code Orange (Disaster) - Code Yellow (IS System Failure)

- No change in the Code Blue or Rapid Response announcement - Emergency Tone + “Emergency Alert” + type of disaster - Emergency Tone + “Emergency Alert” IS downtime (area) - Emergency Tone + “Emergency Alert” Failure of Essential Utilities

standby for further information

Preventing the Spread of Infection STANDARD AND TRANSMISSION-BASED PRECAUTIONS

Infection is caused by germs. An infected person carries germs that he or she can spread to others. Even a person who doesn’t feel sick can still carry and spread germs. Many germs can travel on hands or other things that are touched. Some germs can travel a short distance on droplets when a person talks or coughs.

STANDARD PRECAUTIONS These are practices that all health care workers must follow in the care of ALL patients. They apply to (1) blood, (2) all body fluids, secretions or excretions, (3) non-intact- skin, (4) mucous membranes. They do not apply to sweat.

GLOVES: Are to be worn when the staff member may have hand contact with blood or body fluids, mucous membranes or non-intact skin of ALL patients and when handling contaminated items or surfaces. MASK, EYE PROTECTION, FACE SHIELD: Wear during patient activities that are likely to generate aerosols, splashes, sprays, etc., such as suctioning or intubating. GOWNS: Wear a gown if splashing of blood or body fluids is likely. SHARPS: Never recap, bend or break needles. Place used disposable needles and sharps in a puncture-resistant container at the point of use. EQUIPMENT: Clean equipment with the hospital approved disinfectant. ENVIRONMENTAL CONTROL: Routinely clean and disinfect environment surfaces

such as side rails, over-bed tables, bedside tables and frequently touched surfaces. LINENS: All used linen is considered contaminated. Bag in the standard linen bag at the site. No other precautions are needed.

HAND HYGIENE Wash and sanitize hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. Wash and sanitize hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments. It may be necessary to wash and sanitize hands between tasks and procedures on the same patient to prevent cross-contamination of different body sites. Wash hands with an antimicrobial soap and water whenever hands are visibly soiled. An

alcohol-based waterless skin sanitizer is recommended when hands are not visibly soiled.

WHAT YOU CAN DO

- Follow all instructions when you visit.

- Wash your hands before and after touching the patient, using the bathroom, when you cough or sneeze into your hands or a tissue, and when you leave the patient room.

- Keep your hands away from your face.

WHAT YOU CANNOT DO

- Visit ANY patient if you feel sick or have been exposed to an illness.

- Use the patient’s bathroom.

- Enter rooms with the following signs posted on the doors:

HOW CAN YOU PREVENT THE SPREAD OF INFECTION?

Practicing protective measures such as Standard Precautions, and Personal Protective

Equipment (PPE) will reduce your risk of being exposed to blood borne pathogens.

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