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 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.
Will you provide shot records
in person prior to receiving your Job Shadow badge.
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.
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.