We are growing for our community

100,000 sq. ft. hospital expansion coming soon

Job Shadow Application

Today’s Date:
First Name:
Last Name:
Age:
Date Of Birth:
Address:
City:
State:
Zip:
Email Address:
Phone:
Are you currently enrolled in a college or Program?
What college or program:

Emergency Contact:

Name:
Phone:
Relationship:

Placement Request:

Date Requesting for Shadow:
Location Requesting for Shadow:
Reason for Location Choice:
Learning Expectations:

Signature

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 immunizations is required to begin your shadowing experience. A photocopy of your immunizations record 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)

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 Medical Center.
I will provide a current copy of vaccinations.
Name:
Date:
Digital Signature:


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.

Name:
Date:
Digital Signature:
Submit