Vernon Memorial Job Shadow & Work Experience Program

Dear Job Shadow/Work Experience Applicants,

Thank you for your interest in our Job Shadow / Work Experience Program! We look forward to having you on-site at

our facility!

The Job Shadow / Work Experience Program is a beneficial experience that will help educate and provide insight to

multiple careers within the healthcare setting. Use our Job Shadow / Work Experience Program to gain an in-person

perspective on multiple career paths within various healthcare fields. We are dedicated to making your experience

at Vernon Memorial Healthcare memorable and rewarding.

There are a few things you must accomplish prior to beginning your job shadow/ work experience. This informational

packet will highlight our policies and procedures as they relate to patient privacy. It includes information about

HIPAA (Health Insurance Portability and Accountability Act), which is a set of privacy regulations that all health care

providers are required to enforce. We, as health care providers, are very concerned about our patients’ privacy and

the security of their health care information. Our goal is to help you learn your role in regard to patient privacy and

security.

Please complete all of the forms in this packet. Applicants should allow at least two weeks for processing. There are

several places for your signature. Signing each of the forms means you understand the information and agree to keep

any learned information confidential.

Please direct any questions, and return all completed forms, to Kim Sellers, RN at [email protected]. Office hours are

Monday through Friday 8:00 a.m. - 3:30 p.m. Feel free to also call if you have additional questions: 608-637-4359.

We look forward to seeing you,

Kim Sellers, RN – Health Coordinator

List of Items to Complete or Review:

 View the List of Current Available Areas to Shadow

 Complete the Job Shadow / Work Experience Request Form

 Review & Sign Job Shadow / Work Experience TERMS

 Review & Sign Dress Code Policy

 Review & Sign Confidentiality Agreement

 Complete the Health Form

 TB Risk Assessment Form (if no recent TB test)

Job Shadow Areas

(Subject to Change per Hospital Discretion)

Administration

Imaging (Radiology/X-ray)

Physicians

Anesthesiology

Information Systems (IT)

Physical Therapy

Business Office

Lab

Plant Services

Cardiac Rehab

Laundry

Public Relations and Marketing

Emergency Department

Nursing Dept. (Nurses/CNA)

Purchasing

EMT

Occupational Therapy

Respiratory Therapy

Environmental Services

Patient Accounts/Registration

Speech Therapy

Food and Nutrition Services

Patient and Family Services (Social

Work)

Surgery (Nurses, Physicians or

Surgery Techs)

Health Education

Pharmacy (Pharmacists) (Hospital

and Clinic Pharmacy)

Volunteer Services

HIS (Medical Records)

Pharmacy Techs

Other: Just ask us!

Human Resources

Physician Assistants

When requesting to job shadow a physician or practitioner, please be specific on what type of specialty you are

wanting to shadow. Example: general practice, pediatrics, emergency, surgery, etc.

If requesting to job shadow a nurse, please be specific on what type of specialty you are wanting to shadow.

Example: ER nurse, nurse who works with medical/surgical patients, nurse in a clinic, etc.

If you know the name of the person you would like to shadow in a specific department please indicate that on the

form as well. All attempts will be made to get you paired up with that person.

The more specific your request is, the better chance at getting an experience that will meet all of your expectations.

We will do our best to accommodate specific requests, but please note that staff availability, patient care, and

scheduling will take priority over job shadow / work experience requests.

Vernon Memorial Healthcare

Request for Work Experience Program

Reason For Request:

_____ Job Shadow-High School _____ Job Shadow-College _____ Work Experience _____ School to Work

_____ Other, Please Explain: ____________________________________________________________________

Department or Area of Interest: Days/Time Available:

1st Choice: ________________________________ Times Available: _________________________

2nd Choice: ________________________________ Days (circle all that apply): M TU W TH F

3rd Choice: ________________________________

Your Information (PLEASE PRINT CLEARLY):

Name:________________________________________ Phone Number: _______________________________

Address: _______________________________________________ Email: _________________________________

Date of Birth: ___________________ Gender (circle one): MALE FEMALE NON-BINARY OTHER: ___________

School you attend (if applicable): ___________________________________________________________________

School Contact Person (if applicable): __________________________________ Phone Number: ________________

Emergency Contact:

Name: ___________________________________________ Relationship: _________________________________

Primary Phone Number: _____________________________ Backup Phone Number: _________________________

HEALTH CONDITIONS & VACCINATIONS: Complete the required Health Form attached.

Any other comments or special requests: _____________________________________________________________

_______________________________________________________________________________________________

Job Shadow / Work Experience TERMS:

 Job Shadow applicants must be at least 16 years of age or older.

 Parent signature is required for applicants under the age of 18 years old.

 Vernon Memorial Healthcare will not be responsible for transportation.

 Vernon Memorial Healthcare will not be responsible for lost or stolen items (please only bring necessary

items into building).

 Vernon Memorial Healthcare will not provide reimbursement for any cost associated with the job shadow /

work experience (gas money, time away from work, clothing, etc.).

 Vernon Memorial Healthcare reserves the right to modify, change, or terminate this agreement at any time.

 Vernon Memorial Healthcare reserves the right to end any job shadow / work experience during the

scheduled visit due to any reasons of concern such as safety, behavior, conduct, or breach of terms.

 All packet requirements must be completed and turned in 2 weeks prior to shadow date.

 Job Shadow / Work Experience requests must be approved by Kim Sellers, RN – Health Coordinator and the

department manager where visit will be conducted prior to a visit being scheduled.

Return all completed forms to [email protected]

I agree to the terms & conditions as required by this application:

______________________________________ _________________________

Applicant Name (PRINT) Date

______________________________________ _________________________

Applicant Signature Date

______________________________________ _________________________

Parental Name (PRINT) *Required if under age 18 Date

______________________________________ _________________________

Parental Signature *Required if under age 18 Date

Job Shadow Dress Code

The appearance of job shadow/work experience candidates at Vernon Memorial Healthcare has a direct impact on

patients’ and customers’ perceptions of our professionalism, competency and quality of care. All job shadow/work

experience candidates must adhere to general guidelines. Appearance must not be offensive to our patients and

staff.

Nametag (if applicable) must be worn visibly on the front of outer garments.

Hair must be clean and neat.

Personal Hygiene is important. Each job shadow/work experience candidate is expected to maintain good grooming

habits and hygiene to prevent body odor/bad breath. Limit the use of scented / fragrant products.

Clothing must be neat, clean, in good condition with proper fit. Tight clothing, low cut blouses or clothing that allows

undergarments to show through may not be worn. Skirts, dresses, shorts/skorts should be of moderate length.

Closed-toed shoes must be worn while job shadowing in any patient care area and for those who are involved in

lifting of objects or transfer of patients in any manner (wheelchair, cart, ambulating). Shoes should be kept clean, in

good condition, and reflect the needs of the work performed. *Business Office Setting: Sandals may be worn for visits

with non-patient care roles.

Accessories: Earrings, necklaces, rings etc. may be worn in moderation. Safety and patient care should be considered

when determining whether jewelry/accessories may be worn. Hats will not be worn indoors. No chewing gum is

allowed during patient contact.

*If the job shadow preceptor finds any clothing inappropriate or unprofessional, they reserve the right to cancel or

reschedule the job shadow, until appropriate attire is obtained.

I have read and understand the dress code requirements as indicated above:

Date: ___________________________________________________

NAME (PRINT): ______________________________________________

SIGNATURE: _________________________________________________

Confidentiality Agreement

Job Shadow/Work Experience

Vernon Memorial Healthcare (VMH) has a legal and ethical responsibility to safeguard the privacy of all patients and

to protect the confidentiality of their health information. Additionally, VMH must assure the confidentiality of its

human resources, payroll, fiscal, research, computer systems, and management information.

In the course of my job shadow / work experience at Vernon Memorial Healthcare, I may come into the possession of

confidential information.

By signing this document, I understand the following:

1. I agree not to disclose or discuss any patient, human resources, payroll, fiscal, research and/or

management information with others, including friends or family, who do not have a need-to-know.

2. I agree not to access any information, or utilize equipment without authorization and supervision, even

if I don’t tell anyone else.

3. I agree not to discuss patient, human resources, payroll, fiscal, research or administrative information

where others can overhear the conversation, e.g. in hallways, on elevators, in the cafeterias, on public

transportation, at restaurants, or at social events. It is not acceptable to discuss clinical information in public

areas even if a patient’s name is not used. This can raise doubts with patients and visitors about our respect

for their privacy.

4. I agree not to make inquiries for other personnel who do not have proper authority.

5. I agree not to willingly inform another person of my computer password or knowingly use another

person’s computer password instead of my own for any reason (if applicable).

6. I agree not to make any unauthorized transmissions, inquiries, modifications, or purging of data in the

system. Such unauthorized transmissions include, but are not limited to, removing and/or transferring data

from VMH’s computer systems to unauthorized locations, e.g. home.

7. I agree to log off prior to leaving any computer or terminal unattended (if applicable).

Date: ___________________________________________________

Print Name: ______________________________________________

Signature: _______________________________________________

Vernon Memorial Healthcare Job Shadow / Work Experience

HEALTH REQUIREMENTS FORM

Student Name:_____________________________________ School:______________________________________

Any Health Conditions? YES / NO If yes, please list:____________________________________________________

• The following immunization information are mandatory and must be completed in full.

• Copies of immunization records and/or lab results are needed to verify the information listed below:

please attach a COPY to this form.

MMR – Measles, Mumps, Rubella Vaccine:

2 MMR’s are required – or dates & results of Titers

Date of vaccine #1:__________, #2:__________

OR

Measles Titer Date:_________ Result:__________

Mumps Titer Date:_________ Result:__________

Rubella Titer Date:_________ Result:__________

Chicken Pox (Varicella) Vaccine:

Vaccine not needed if past history of having chicken pox.

History or disease: YES / NO

Date of vaccine #1:__________, #2:__________

OR

Varicella Titer Date:_________ Result:__________

Hepatitis B Vaccine:

3 Hep B vaccinations are required

OR a signed declination form.

Date of vaccine #1:__________

#2:__________

#3:__________

OR

Complete Signed Declination Form: ________________

TB Skin Test:

Negative TB skin test

OR complete TB Risk Assessment Form

Date of TB test:_________ Result:__________

_________ Result:__________

OR

Complete attached TB Risk Assessment Form: _____________

Flu Vaccine (November 1 – April 30):

Must have flu vaccination if job shadowing during above months.

Date of Flu Vaccine:_________________

COVID-19 Vaccine - MANDATORY

Brand: ______________ Dose 1: ____________ Dose 2: ____________

Health requirements and policies apply to all students coming for job shadow / work experience. It is the

student’s responsibility to submit accurate and timely information.

To the best of my knowledge, the above information is correct, and I do not currently have a communicable

disease or health condition that would put the patients/clients/staff or myself at risk.

_______________________________________________ ____________________________

Student Signature Date

_______________________________________________ ____________________________

Parent Signature (if student is under 18) Date