The Right Care, Right Here

Top-quality compassionate medical care, close to home.

Job Shadow Application

Today’s Date:
First Name:
Last Name:
Age:
Date Of Birth:
Address:
City:
State:
Zip:
Email Address:

Emergency Contact:

Name:
Phone:
Relationship:
Date Requesting for Shadow:
Location Requesting for Shadow:
Digital Signature:
Print Name:
Date:

Immunization Record:

Name:
Today’s Date:
Home Address:
Department Shadowing:

We are dedicated to protecting you and our patients from infectious disease. The chart below must be filled out for the listed vaccinations. Also, documentation of the following immuniza-tions is required to begin your shadowing experience. A photocopy of your immunizations rec-ord must be attached to this form as proof of immunization.

Required Vaccinations

Date of Vaccination

( mm/dd/yyyy)

Clinic or physician’s office where vaccinated

Upload Files below

2 Varicella vaccinations, written documentation of disease (Chicken Pox) from healthcare provider, or laboratory evidence of immunity.

2 MMR vaccinations or laboratory confirmation of disease immunity.

Tdap (Tetanus/ Diphtheria/ Pertussis)

Flu Shot ( Beginning October 1st and continuing through current active flu season in Howell County)

Job Shadow Acknowledgement Checklist (Check each item to indicate understanding)

I understand that I may be asked to step out of the area at any time by a patient or OMC coworker.
I will not be on my cell phone during my job shadowing experience.
I will remember that I am a guest at OMC and I will respect those around me.
I will adhere to the dress code during my job shadow experience.
If I do not adhere to the basic courtesy rules and do not pay attention during my shadow expe-rience, I may be asked to leave the department.
Name:
Date:
Digital Signature:


Statement of Confidentiality

Ozarks Medical Center has a legal and ethical responsibility to safeguard the privacy of all pa-tients and protect the confidentiality of their health and financial information. In the course of my job shadow, I may come into possession of or gain knowledge of such confidential infor-mation.

I understand that such information must be maintained in the strictest confidence and should be made available only to those who need to know. During the course of my job shadow, I will not examine, copy, or discuss information coming into my possession and will not permit any other person to do so unless it is needed for patient care, risk management, billing, maintaining or dis-tributing records authorized by the patient.

I understand divulging information or having unauthorized possession of confidential infor-mation relating to patients, employees, or the business of Ozarks Medical Center is considered proper cause for disciplinary action.

Name:
Date:
Digital Signature:
Submit