Thank you for your interest in The Shadow-A-Professional program that allows high school junior and senior students interested in the hospital industry to explore career options and/or gain experience to add to their resume when applying to college. A limited number of students will be accepted into the program, based upon the following criteria: Current High school juniors or seniors will be considered. The Volunteer Services Coordinator will conduct the interviews for those students being considered for the program May 16 th May 27 th between the hours of 3:00pm 4:30pm. Interviews last approximately 20 minutes. Acceptance / rejection letters will be mailed the first full week of June. Upon acceptance into the program, students are required to attend New Volunteer Orientation and training Monday, July 11, 2016, 8am- 1pm in our Kurth Auditorium. The one-week program will begin Monday July 11 th and end Friday July 15 th. Students who are accepted must commit to participating in the Shadow Program for the full 5 days. Students are encouraged to purchase a Student Volunteer Jersey for $10. Volunteering in the hospital before and after Shadow-A-Professional Program is welcomed and encouraged. Student Responsibilities Submit all documents in one complete packet by Friday, May 6 th 4:00pm deadline. Packets must be in the office on that date, not postmarked by that date. Hand delivery is acceptable. No applications will be accepted after this date. Please do not enclose your application in a binder or dividers. 1. Submit a completed Shadow-A-Professional application. 2. Submit a photocopy of your student identification, driver s license or other photo. 3. Submit the Health Screening form completed by your personal physician. Copies of immunization records are also acceptable. 4. Submit one TB test result with application. PPD/Tuberculosis Skin Test 2 Step- Mandatory. Must be within 12 months of July 2016. If accepted, you will need to provide your second TB test results at orientation scheduled Monday, July 11, 2016. 5. Submit your Flu Vaccination for the current Flu season (2015-2016) if you received a vaccine. 6. Submit the following questions and answer each question in a short essay form: 1. Tell us about yourself, and why you are interested in being a part of the Shadow-a-Professional Program at Lawrence General Hospital. 2. List your 1 st, 2 nd, & 3 rd choice where you want to shadow, and why you chose these areas. (Students accepted will observe only one site during the 5 day program). See next page for available departments. 7. Submit two (2) letters of recommendation from teachers or mentors. 8. Submit a parental signed agreement stating that the student will commit and be present during the entire 5 day program (see page 3). No exceptions will be made with these dates. 1
Departments Participating in the Shadow-A-Professional Program: Cat Scan 8am-3pm - Student will observe in-patient, out-patient areas and emergency Cat scan exams including but not limited to trauma and stroke. Hospitalists 8am-1pm - Student will observe doctors as they perform daily rounding and will be trained in topics such as common illnesses, family medicine practices and palliative care. Inpatient and Outpatient Rehab Departments 8am-3pm- The student will observe both inpatient and outpatient Rehab departments and they will spend some time with Physical Therapists, Occupational Therapists, and Speech Therapists. Pediatric Unit 8am-1pm - Student will observe Pediatric doctors as they perform daily rounding, and will be trained in topics such as common childhood illnesses, and family medicine practices. Student will observe the workings of the Pediatric unit. They will also observe Pediatric nursing care. Pharmacy 8am 3pm - Student will observe the sterile technique of IV preparation, the use of automation to dispense medication, and unit dosing medication. Student will accompany staff as they deliver medications to units. Purchasing Department - 8am-1pm - Purchasing function surrounding the Operating Room, Emergency Center and Medical/Surgical Unit requirements. Radiology 8am 1pm The student will be able to observe exams conducted in the department as well as in the Emergency Center. In some instances, they may be able to observe some exams in Cat Scan. Telemetry Unit 8am 1pm - Student will observe nursing staff as they treat a variety of patients and student will observe the workings of the Telemetry Unit. Triage RN 9am-3pm - The student will learn how a triage nurse uses the Emergency Severity Index (ESI) to rate patient acuity from needing lifesaving treatment to least amount of resources needed to provide patient care. The student will observe how the triage RN determines which area of the department the patient will be evaluated and treated in, (main EC or Rapid Medical Evaluation, triage 2 area). The student will also learn/observe the triage RN ordering diagnostic testing per standing MD order sets for specific patient ailments/ complaints, thus improving patient satisfaction and decreasing Length of Stay. o The student will observe the role of the EC Trauma Tech assigned to work with the Triage RN. (EKG s, splint applications, collection of urine samples, escorting patients to patient rooms, diagnostic testing area and registration). The student will see how the EC staff members work together as a team. 2
Mail packets to: Brenda LeBlanc, Volunteer Services Coordinator Lawrence General Hospital 1 General Street Lawrence, MA 01841 : Commitment Agreement for the 2016 Shadow-a-Professional Program I agree that if I am accepted to the Lawrence General Hospital Shadow-a-Professional Program, I: understand that the program begins Monday, July 11 and ends Friday, July 15, 2016. will commit to being available for the entire 5 days. I will be present for all shifts that I am assigned to. agree that I will attend volunteer orientation Monday, July 11 th 9am 1pm and other necessary training that will be required. will submit the required documents noted under Student Responsibilities. understand that if I cannot commit to the above requirements, I forfeit the opportunity to participate in this program. Student Name: Student signature: Date: Parent/Guardian name: Parent/Guardian signature: Date: 3
Office Use Only Application Received Interview Orientation CORI TB1 TB2 PIN # Jersey $10/Size Shadow-A-Professional Program - Must be a Junior or Senior in High School to apply. Applications are due Friday, May 4, 2016, 4:00pm. This program allows high school junior and senior students who are interested in the hospital industry to explore career options and/or gain experience to add to a resume when applying to college. This 5 day program runs from July 11 th to July 15 th, 2016. PERSONAL INFORMATION First Name Last Name Street Address Apartment # City State Zip Code Home Phone Cell Phone Work phone Email Address _Date of Birth (optional) SCHOOL, VOLUNTEER AND WORK EXPERIENCE: I am a high school Junior Senior Please list current school Describe current & previous work experience Describe current & previous volunteer experience BACKGROUND How did you learn about the Shadow-A-Professional Program? Have you ever been employed, volunteered or applied previously at this hospital? List any special skills and interests that you have: 4
EMERGENCY CONTACT Name Relationship to you Phone (This is a: Home Cell Work number) SIGNATURE The information on this application is true to the best of my knowledge. I understand that false statements made as part of this application will be considered cause for dismissal. I understand that if I am accepted as a Shadow-A-Professional, I will not be paid for my services. I understand that if I am accepted as a Shadow-A-Professional, I will agree to abide by the guidelines of the Volunteer Services program. I grant authorities of this hospital to investigate my references. I understand that Criminal Offender Record Information (CORI) checks are required for all applicants over the age of 18. Acceptance to the volunteer program is contingent upon successful clearance of CORI evaluation. Applicant Signature Date *If you are under 18 years of age, the signature of a parent or guardian is required. Signature Date Notes: Office Use Only 5
Name: Date of Birth: Directions: Please take this form to your health care provider for completion. ** A copy of your immunization records or your school health record is acceptable. The lab tests needed when immunization records are not available may be costly, and you are responsible for payment. Please be diligent in getting your records from your private physician, school record or previous employer. For Health Care Provider Completion: For this individual to qualify to volunteer at Lawrence General Hospital, there are minimal infection control standards that need to be met. A list of the standards is included in this packet. Please complete the form below with special consideration to the following: If there is no evidence of measles and/or rubella immunity, please administer MMR or draw titer(s). Questions with this form, 978-683-4000, extension 2645. Thank You. Signature of Health Care Provider: Measles, Mumps, Rubella: For volunteers working in Emergency, Pediatrics, or Maternal Child Health as greeters or escorts TDAP Date: MMR #1 Date: MMR #2 Date: TDAP Date: For volunteers working in Emergency, Pediatrics, or Maternal Child Health as greeters or escorts. Chicken Pox/Varicella: History of Chicken Pox: Yes No If No History: Titer: or For volunteers working in Emergency, Pediatrics, or Maternal Child Health as greeters or escorts. Vaccination Date: #1 #2 Hepatitis B Vaccine Required for volunteers with potential exposure to blood borne pathogens. *Provided by LGH if necessary. Hepatitis B Vaccine Date # 1: Hepatitis B Vaccine Date # 2: Hepatitis B Vaccine Date # 3: Or Declination Signed: PPD/Tuberculosis Skin Test - 2 step STEP 1 STEP 2 Date Planted: Date Planted: Must be within 12 months of start date or be Date Read: Date Read: replanted. -Steps can be 2 weeks apart *Provided by LGH if necessary. Result in mm: Result in mm: Flu Vaccine Mandatory during Flu Season Flu Vaccine Date: Occupational Health, 2 nd Floor, 25 Marston Street, Lawrence, MA Monday Friday, 8:30am 4:00pm 6
Infection Control Standards for Health Clearance Tuberculosis Screening and Chest X-Rays. One of the following is required: A. Two (2) PPD Skin tests within the past 12 months; or B. For individuals known to be PPD test positive, there needs to be a record of a negative chest x-ray report done. Measles and Rubella Immunity. The following is required: A. Documentation of two MMR vaccines, or B. Proof of immunity to measles, mumps and rubella by titer (blood test done by your private Physician. Please note that you will be responsible for payment for this test.) Hepatitis B Vaccine. For individuals who may be exposed to blood or body fluids during their experience at LGH: A. Documentation of the Hepatitis B series, or B. Positive antibody test for hepatitis B will be done our Occupational Health Department. * LGH will provide this vaccine free of charge to individuals who may be exposed to blood or body fluid during their work. Chicken Pox: Anyone who does not have a history of chicken pox is strongly recommended to get the chicken pox (varicella) vaccine from his/her primary care provider. As an adult, chicken pox can be a very serious illness. Flu Vaccine: 100% compliance during Flu Season, Usually October May of every year. * Please refer to LGH Occupational Health Services Infection Control Policy Reference: MDPH Adult Immunizations; recommendations & requirements for 2011 7