Job Shadow Application
Date Of Birth:
Are you currently enrolled in a college or Program?
What college or program:
Date Requesting for Shadow:
Location Requesting for Shadow:
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 immunizations is required to begin your
shadowing experience. A photocopy of your immunizations record must be
attached to this form as proof of immunization.
I will provide, in person, a photo copy of my current vaccination records.
Job Shadow Acknowledgement Checklist (Check each item to indicate understanding)
I understand that I will be asked to provide a copy of my photo ID.
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 experience, I may be asked to leave the department.
I understand that I am not to enter any patient’s room that is under
airborne isolation precautions.
I understand that this agreement only covers observation hours at Ozarks
I will provide a current copy of vaccinations.
Statement of Confidentiality
Ozarks Medical Center has a legal and ethical responsibility to safeguard
the privacy of all patients 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 information.
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 distributing records authorized by the patient.
I understand divulging information or having unauthorized possession of
confidential information relating to patients, employees, or the business
of Ozarks Medical Center is considered proper cause for disciplinary action.