First Name: *  

Middle Initial: *  

Last Name: *  

Email Address: *  

Street Address: *  

City: *  

State: *  

Zip: *  

Phone: *  

Varicella Immunization

Option 1 - I have had Chickenpox

Option 2 - I have been informed that a Titer can be done to determine my immunity. I understand that I can have this Titer at my expense. I also understand that should the Titer indicate that I am non-immune to varicella (the virus that causes chickenpox); it is recommended that I obtain the varicella immunization, also at my expense. I wish to obtain the Titer and if necessary, the vaccine and will provide proof of these prior to work.

Option 3 - To my knowledge, I have not had Chickenpox. I have been informed that a Titer can be done to determine my immunity. I understand that I can have this Titer at my expense. I also understand that should the Titer indicate that I am non-immune to varicella (the virus that causes chickenpox); it is recommended that I obtain the varicella immunization, also at my expense. At this time, I choose not to receive the Titer to determine my immunity, and I should be aware that I may not be immune and that: I may contract varicella as a result of this agreement, (by exposure to chickenpox or shingles); If I am pregnant and contract varicella, this may result in serious consequences for both the mother and fetus.; Should I contract varicella, I may carry the illness to patients, employees, or persons in the community including my family and friends. ; If I am exposed to varicella virus (chickenpox or shingles), I am to notify Employee Health and my employer/school immediately. I will be relieved from duty from day 10-21 post exposure. However, I also understand that by signing this form today does not prohibit me from obtaining the Titer and vaccine at a later date.

Varicella Immunization Student Form (please mark one based on criteria above):

Option 1: I have had Chickenpox
Option 2: have been informed that a Titer can be done to determine my immunity.
Option 3: To my knowledge, I have not had Chickenpox. I have been informed that a Titer can be done to determine my immunity. 

HEPATITIS B VACCINE NOTICE/DECLINATION:

Option 1: I have had the vaccine - proof on file
Option 2: I understand taht I need to arrange for vaccination 

HIV-POST EXPOSURE PROPHYLAXIS

Although preventing blood exposure is the primary means of preventing occupationally acquired human immunodeficiency virus (HIV) infection, appropriate post-exposure management is an important element of workplace safety. Immediate treatment may reduce the risk for HIV transmission. If you are exposed to blood or body fluids from a person know to be HIV positive, you should report this immediately to your employer/school (if applicable). Treatment should be initiated promptly, preferably within 1-2 hours, and may be administrated at MSHA through the Emergency Department or at the healthcare provider of your/your employer’s/your school’s choice. If treatment is provided at MSHA, it would be provided at your expense.

I have read and understand the Hepatitis B and HIV Exposure notices.

Confidentiality Agreement

This agreemment is between the Student listed above and Mountain States Health Alliance

Mountain States Health Alliance has a long tradition of protecting the privacy of patient information, including patient names, addresses, telephone numbers, social security numbers, diagnoses, pharmacologic and surgical interventions as well as the testing and results associated with the delivery of care to a patient at any MSHA facility. MSHA’s commitment to patient confidentiality is reinforced by the privacy and security regulations created as part of the Health Insurance Portability and Accountability Act (“HIPAA”).

In addition, MSHA has intellectual property that must be protected. Such information may be disclosed for purposes for particular business purposes. MSHA business related property must not be used, copied, distributed or disclosed without appropriate authorization or contractual agreement.

By signing this agreement, I understand that maintaining the confidentiality of patient and business information is a condition of my continued relationship with MSHA. Therefore, I agree to maintain the confidentiality of all patient information, as well as any business related information that may become known to me in the course of my relationship with MSHA. This includes patient and business information that may be incidentally disclosed to me as a result of my presence in a MSHA facility.

I understand that any breach in confidentiality, including but not limited to any inappropriate use or disclosure of patient information is a violation of MSHA policy, and such a breach will result in appropriate actions, up to and including termination of my relationship with MSHA. In addition, such a violation may be considered a violation of federal regulations and be subject to investigation by the Office of Civil Rights.

Confidentiality Principles

• It is an expectation and responsibility of anyone who provides services for or within any MSHA facility to insure the utmost privacy and security of patient and business related information. This includes all information whether written, spoken, observed, in a computer system, or any other form or media.
• Patient information will be managed in accordance with MSHA policies; and all applicable state and federal requirements. Patient information will only be accessed, used or disclosed in a manner necessary to perform job duties based on a need to know. It is a patient’s right to expect that their information will be treated in a confidential and secure manner. The patient has the right to expect that their health information will be safeguarded and protected.
• Patient information will be used or disclosed only as needed to support the purpose of the intended use or disclosure consistent with professional judgment and reasonableness. It is an expectation of anyone disclosing patient information to insure they are authorized to do so, to know whether the recipient is authorized to receive the information and to insure the request is appropriate for the content and purpose within professional judgment and reasonableness.
• Patient information will be protected from any intentional or unintentional use or disclosure that is in violation of MSHA policy, and/or state and federal regulations. Any breach in confidentiality of patient information is a violation of MSHA policy, and such a breach will result in appropriate actions, up to and including termination of my relationship with MSHA. In addition, such a violation may be considered a violation of federal regulations and be subject to investigation by the Office of Civil Rights.
• MSHA business and intellectual information is considered property of MSHA. It may not be used directly or indirectly for personal gain, nor be used, copied, distributed or disclosed without appropriate authorization. Anyone possessing proprietary information must handle the information in a manner so as to protect it against improper access, use or disclosure.
• Copyrighted materials may not be duplicated without written permission of the license holder for use on MSHA premises or elsewhere.
• It is an expectation that all team members and those doing business with MSHA conduct their behavior in a manner consistent with basic workplace compliance and ethics standards.

printable pdf of this agreement

Instructor's Name: *  

Please select the name of your school: * Appalachian State University Belmont University Chattanooga State East Tennessee State University King College Mayland Community College Milligan College Mountain Empire Community College Mountain State University MSHA CNA Northeast State Community College Ohio University Radford University South College Southeast Kentucky Community College Southwest Virginia Community College Tennessee Technology Center University of KY University of TN UVA Wise Virginia Highlands Community College Walters State Community College Wytheville Community College Other  

Please select you school program: * Business & Technology Certified Nursing Assistant Dietary/Food & Nutrition Exercise Science Nursing Occupational Therapy Paramedic / EMT Pharmacy Phlebotomy Physical Therapy Polysomnography Psychology / Counseling Public Health Radiography Respiratory Speech Social Work Surgical Tech Other  

Please choose what your rotation is for: * Job Shadowing / Observations Purposes Only MSHA CNA Program / New Hire Senior Internship School Clinical Rotations  

Ageement:

I Accept