(907) PHONE (907) FAX

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1 3260 Hospital Drive Juneau, AK Application for Medical, Nurse Practitioner, and Physician Assistant Students Bartlett Regional Hospital Medical Staff Services Office 3260 Hospital Drive Juneau, AK (907) PHONE (907) FAX This application applies to all Medical, Nurse Practitioner, and Physician Assistant Students seeking to participate in clinical rotation training and education opportunities at Bartlett Regional Hospital. 1. All information must be TYPED or CLEARLY HANDWRITTEN. (Applications that are not legible will be returned) 2. No part of the application may be completed by referring to or writing, See Curriculum Vitae and/or See Enclosed/Attached. Any areas that do not apply to the applicant should be marked with N/A leaving no blank areas on the application. (Applications deemed incomplete will be returned for completion) 3. All applicants are required to submit the following: This application - completed Completed Supervising Physician & Scope of Practice Form for each physician the student will work with (page 4) Copy of current Driver s License or other government issued ID Copy of Malpractice Coverage Face Sheet provided by educational institution Current Curriculum Vitae Certificate of Education degree (if applicable) Letter from Educational institution confirming you are currently enrolled in a medical/nursing program in good standing Current PPD Tuberculosis Screening (Within past 12 months) and Current Vaccination\Immunization Record Personal Information Last Name First Name Middle Name Gender Male Female Current Year Student (please circle one) Dates of Hospital Rotation From: To: Other Names By Which You Have Been Known/Maiden Name Student Specialty Medical Student Nurse Practitioner Physician Assistant Name of Sponsoring Physician Clinical Specialty During Rotation Sponsoring Physician Clinic Name Social Security Number Home Street Address Home City/State/Zip Home Phone Number Home Fax Number Cell Phone Number Address Date of Birth Birth City/State Birth Country Citizenship Marital Status (optional) Education and Training:( No part of the application may be completed by referring to or writing See Curriculum Vitae and/or See Enclosed/Attached etc.) UNDERGRADUATE EDUCATION: Name of Institution Start MM/YYYY End MM/YYYY Mailing Address City, State Zip Type of training/specialty/major Was program successfully completed? If yes, what degree was awarded Your Program Director/Dean? Yes No If no, explain Current Program Director (if applicable) Phone Number Fax Number Address 1 Applicant Initials:

2 MEDICAL/NURSING/PHYSICIAN ASSISTANT EDUCATION: Name of Institution Start MM/YYYY End MM/YYYY Mailing Address City, State Zip Type of training/specialty/major Was program successfully completed? If yes, what degree was awarded Your Program Director Yes No If no, explain Current Program Director (if applicable) Phone Number Fax Number Address Work History: N/A (check here if this section does not apply to you) List all work history experience that is related to healthcare, and/or the medical profession, and/or group or solo practice, etc. since the beginning of your education in healthcare or for the past five-(5) years, whichever is less. Begin with most current and list in chronological order. ( No part of the application may be completed by referring to or writing See Curriculum Vitae and/or See Enclosed/Attached etc.) Name of Current Practice/Employer Start MM/YYYY End MM/YYYY Mailing Address City, State Zip Phone Number Fax Number Clinical/Supervisor Contact Phone Number Type of Practice Position Held/Title Reason for leaving (if applicable) Name of Practice/Employer Start MM/YYYY End MM/YYYY Mailing Address City, State Zip Phone Number Fax Number Clinical/Supervisor Contact Phone Number Type of Practice Position Held/Title Reason for leaving (if applicable) Malpractice Coverage Provide a copy of malpractice insurance face sheet that indicates coverage provided by educational institution. IMPORTANT NOTE: Policy requires professional liability insurance in the amount of 1,000,000/3,000,000 or greater to apply for clinical training experience. Name of Present Carrier How long? Policy Number Complete Address Phone Number: Fax Number: Coverage Amounts Initial Date / End Date of Coverage IF YOU ANSWER YES, PLEASE PROVIDE DETAILED INFORMATION ON A SEPARATE SHEET. 1) In the past five years, has there been or are there currently, any claims, lawsuits, settlements or judgments against you where you are named, even if not resulting in monetary damages, or have you received any notice of Intent to File? 2) Have you ever had any professional liability insurance coverage canceled, declined or modified (i.e., reduced limits, restricted coverage), or has any renewal ever been refused, or have you voluntarily given up coverage? 3) If you have ever been a federal, military or tribal employee, have you ever been named as a responsible party in a merited lawsuit against the United States Government that resulted in a financial settlement or payment? 4) Has your professional liability insurance coverage ever been terminated, not renewed, restricted, or modified, or have you ever been denied professional liability insurance? Yes No Pending Yes No Pending Yes No Pending Yes No Pending Applicant Initials: _ 2

3 HEALTH STATUS IF YOU ANSWER NO, PLEASE PROVIDE DETAILED INFORMATION ON A SEPARATE SHEET. Are you able to safely and competently exercise the clinical scope of practice authorized during clinical rotation(s)? Yes No Are your Immunization Records Current to include Non-reactive TB test (0 mm PPD) or medical clearance (must be current within past 12 months)? Yes No IF YOU ANSWER YES, PLEASE PROVIDE DETAILED INFORMATION ON A SEPARATE SHEET. Do you have or have you recently had any physical condition, mental health condition, or chemical dependency condition (alcohol or other substance) that affects or is reasonably likely to affect your current ability to practice with our without reasonable accommodations regarding the student privileges requested? Do you presently have a physical or mental condition that affects or is reasonable likely to affect your ability to perform student duties appropriately? Yes No Are you currently under care for any physical, mental, or substance abuse problem? Yes No Have you at anytime during the last five (5) years been hospitalized or received any other type of institutional care for a physical, mental health, or substance abuse problem? Yes No DISCLOSURE QUESTIONS. Disclosure Questions- If you answer YES to any questions number 1 through 4, please provide details on a separate page. Include a copy of any order or settlement where applicable. 1. Have you ever been convicted of, or pleaded guilty or nolo contenders to any crime other than a minor traffic violation, or are charges pending against you for any such crimes by information, indictment or otherwise? 2. During the last five years, have you been under the influence of alcohol during working hours or have you used illegal drugs? If YES, please provide details. 3. Are you currently using any chemical substance(s), legal or illegal, that in any way impairs or limits your ability to practice medicine in a safe and competent manner? Yes Yes Yes Yes No No No No The information given in or attached to this application is accurate and complete to the best of my knowledge, information and belief. By placing my signature below, I understand that this student experience at Bartlett Regional Hospital is intended to provide me with training and educational opportunities. I understand that I am not permitted to discuss patient/resident conditions with patients/residents and/or their family members, nor am I to discuss what I have heard/seen and/or learned during my student experience with anyone outside of those appropriate persons in the Bartlett Regional Hospital system. I understand that my doing so, may constitute a HIPAA privacy violation. Signature of Student: Date: 3

4 DEFINITIONS AND PRIVELGES 1. All Medical, Nurse Practitioner, or Physician Assistant Students covered under the BRH Medical, Nurse Practitioner, and Physician Assistant Students policy will adhere to the regulations of Bartlett Regional Hospital, and those of the organized BRH Medical Staff. 2. Medical, Nurse Practitioner, or Physician Assistant Students will not practice outside the delineated privileges signed by the sponsoring physician and the approving committees. 3. Neither the patient, nor any other payer, will be charged for services provided by the student. 4. The student may write admission history and physical examinations, write progress notes and write orders. All medical record entries must be read, corrected or agreed with, and signed by the sponsoring physician. Student orders will be co-signed before being implemented. 5. Students may draw blood, start IVs, or do other minimally invasive procedures under the direct supervision of the sponsoring physician or his/her physician designee. 6. The student may scrub in surgery or assist in labor and delivery under the direct supervision of the sponsoring physician or his/her physician designee, after obtaining consent from the patient. In Hospital Care - Any care provided within the physical confines of the hospital to include the Emergency Rooms. Briefly summarize the specific duties and responsibilities, including surgery, which the student will perform in the hospital and not outside the scope of practice listed in BRH Medical Staff Policy (The sponsoring Physician needs to indicate Yes or No ): YES NO To be signed by the Sponsoring Physician: It is my understanding that the student will perform only those privileges as granted. Signature of Sponsoring Physician: Date Printed Name of Sponsoring Physician: Signature of Student: Date Signature of Credentials Committee Member: _ Date 4

5 Guidelines for Practicing Confidentiality Information about patients should not be discussed in a public setting. When a patient is your neighbor or friend, you should be particularly careful not to reveal any information to mutual friends. Patient information should not be discussed with health care workers not directly involved in their care will not disclose, release or discuss any patient information, including clinical information of any kind, such as medical conditions, financial / social information or patient demographic information. Medical and nursing records should not be left at any location where unauthorized personnel can see them. Patients must give permission for information (such as diagnosis) to be revealed to anyone. A patient may withdraw permission at any time. Such permission must be documented in the medical record of the patient. Patient information should not be discussed where it can be overheard by visitors and/or the public. When a patient is your neighbor or friend, you should be particularly careful not to reveal any information to mutual friends. No information about patients should be revealed to reporters, press, or media. Interviews with confused or disoriented patients are not permitted without family and/or physician's permission. I will follow the BRH Fragrance free Workplace/Personal Appearance Policy. I will not use my cell phone(s) or camera(s) during my shadow rotation. I will not use nicotine products, alcohol or any mood altering chemicals during my job shadow and while on BRH property. CONFIDENTIALITY AGREEMENT I,, have read the guidelines above and agree to abide by them and do hereby agree to keep all information obtained regarding patients and/or physicians confidential. I hereby agree not to discuss any information obtained during the course of this educational rotation. I release Bartlett Regional Hospital and its representatives of any liability arising from a breach of confidentiality caused by myself. Signature: Date: Printed name: 5

6 BARTLETT REGIONAL HOSPITAL 3260 Hospital Drive Juneau, Alaska Telephone Authorization to Release Information for Medical, Nurse Practitioner, and Physician Assistant Students I hereby authorize Bartlett Regional Hospital to consult with members of the educational institution, medical staff of other hospitals with which I have been associated, and with others who may have information bearing on my competence, character, and ethical qualifications and competence to carry out the clinical qualifications for staff membership. I hereby release from liability all representatives of the hospital and its medical staff for their acts performed in good faith and without malice in connection with evaluation of my application and credentials. I hereby release from any liability all individuals and organizations who provide information to the hospital in good faith and without malice concerning my competence, ethics, character, and other qualifications for staff appointment and clinical privileges, including otherwise privileged or confidential information. A duplicate copy of this page constitutes my written authorization to request supportive documentation regarding this application. _ Applicant Name (Please print) Applicant Signature Date MEDICAL STAFF OFFICE Direct Number: (907) Web Site: Fax Number: (907)

7 BARTLETT REGIONAL HOSPITAL 3260 Hospital Drive Juneau, Alaska Telephone Student Name: (Please print) Agency: Privileges requested: Date of Assignment or Targeted Beginning Date: All Students are required to complete a current (within the past 12 months) tuberculosis screening. Tuberculosis PPD skin test can be done in any Nursing Department and read 48 to 72 hours later by any qualified nurse, physician, or the Infection Control Coordinator. If you have had a positive PPD in the past please do NOT get a PPD skin test. Your previous PPD Tuberculin Skin Test was: positive or negative dated Take this form to any Nursing Department for Tuberculosis PPD skin testing. PPD skin test placed 0.1 cc intra-dermal forearm Date Lot # Expiration Date _ Nurse's Signature Have PPD read on or at 48 to 72 hours Date read Results mm. Nurse's Signature Return with BRH Student Application 7

8 3260 Hospital Drive Juneau, Alaska (907) Name: Date of Birth: Contact phone #: _ Duration of Student Rotation: From To REQUIREMENTS (IMPORTANT! BRH does not allow exemptions): 1. MMR (Measles, Mumps, Rubella) 2. Varicella (Chicken Pox) 3. Tdap (Tetanus, Diptheria, Pertussis) Documented MMR vaccine x 2 OR Positive titer showing immunity o Measles o Mumps o Rubella Varicella vaccine x 2 OR Positive Varicella titer OR History of disease Tdap vaccine NOTE: The following additional immunizations are not required but are recommended: 1. Hepatitis B 2. Influenza **If affiliated with a School or Organization please review and sign below: I attest that the following immunization requirements for the above-named individual have been met and will remain active and current for the duration of their time at Bartlett Regional Hospital and that supportive documentation is maintained by the school/organization and can be provided upon request. Student/participant has ALL required immunizations. Student/participant has exemptions or does not have required immunizations (will not be allowed to participate). School/Organization Name: Student Signature Date: Instructor/School Official Signature: _ Date: BRH Medical Nurse Practitioner Physician Assistant Revised Application.doc November 16,

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