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Galen Clinical Documents
Fundamentals (NUR155)
Galen College of Nursing
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HCA Florida Healthcare Student Screening Checklist School Send to Clinical Rotation Coordinator at individual facility. paperwork MUST be submitted 2 weeks prior to the rotation start Any deviation from this timeline will result in a delay of clinical experience. Rotation Information HOSPITAL Name: SCHOOL Name: Degree Program: Galen College of Nursing Student Name: Sergeline Daquin ADN Requirements Faculty School Student Documentation Criteria Standards Rep Initials Must be completed and signed the student prior to the commencement Exhibit A: Statement of Responsibility of the Clinical Program rotation Exhibit B: Workforce Member Must be completed and signed the student prior to the commencement Confidentiality Security Agreement of the Clinical Program rotation Exhibit C: Attestation of Satisfactory Must be completed and signed a school representative prior to the Background Investigation Drug Screen commencement of the Clinical Program rotation Must be completed and signed the student with respect to applicable Student Orientation and Code of Hospital policies and procedures, prior to the commencement of the Clinical Conduct Acknowledgement Program rotation Must be completed the student and score verified a school Competency Assessment representative prior to the commencement of the Clinical Program rotation Proof of Influenza vaccination or a signed declination form must be uploaded a school representative or the student to the HCA FluTracker Influenza Vaccination Record during flu season (October 1 March 31, or as defined CDC) I (Instructor School Representative) here attest the above criteria and student documentation provided is true, accurate, and complete. I further attest that the student data entered above has been verified and is producible upon request. Additionally, the student has demonstrated and is competent in proper hand hygiene. Signature (Instructor School Representative): Date: Rep Phone: Rep Email: Revised HCA Florida Healthcare Student Screening Checklist School Send to Clinical Rotation Coordinator at individual facility. paperwork MUST be submitted 2 weeks prior to the rotation start Any deviation from this timeline will result in a delay of clinical experience. Rotation Information HOSPITAL Name: SCHOOL Name: Degree Program: Galen College of Nursing Student Name: Sergeline Daquin ADN Requirements Faculty School Student Documentation Criteria Standards Rep Initials Must be completed and signed the student prior to the commencement Exhibit A: Statement of Responsibility of the Clinical Program rotation Exhibit B: Workforce Member Must be completed and signed the student prior to the commencement Confidentiality Security Agreement of the Clinical Program rotation Exhibit C: Attestation of Satisfactory Must be completed and signed a school representative prior to the Background Investigation Drug Screen commencement of the Clinical Program rotation Must be completed and signed the student with respect to applicable Student Orientation and Code of Hospital policies and procedures, prior to the commencement of the Clinical Conduct Acknowledgement Program rotation Must be completed the student and score verified a school Competency Assessment representative prior to the commencement of the Clinical Program rotation Proof of Influenza vaccination or a signed declination form must be uploaded a school representative or the student to the HCA FluTracker Influenza Vaccination Record during flu season (October 1 March 31, or as defined CDC) I (Instructor School Representative) here attest the above criteria and student documentation provided is true, accurate, and complete. I further attest that the student data entered above has been verified and is producible upon request. Additionally, the student has demonstrated and is competent in proper hand hygiene. Signature (Instructor School Representative): Date: Rep Phone: Rep Email: Revised EXHIBIT A STATEMENT OF RESPONSIBILITY For and in consideration of the benefit provided the undersigned in the form of experience in a clinical setting at the undersigned and heirs, successors assigns do here covenant and agree to assume all risks and be solely responsible for any injury or loss sustained the undersigned while participating in the : at Hospital unless such injury or loss arises solely out of gross negligence or willful misconduct. the Signature of Program Sergeline Name Dagun Date Parent or Legal Guardian Date If Program Participant is under 18 Print Name EXHIBIT A STATEMENT OF RESPONSIBILITY For and in consideration of the benefit provided the undersigned in the form of experience in a clinical setting at the undersigned and heirs, successors assigns do here covenant and agree to assume all risks and be solely responsible for any injury or loss sustained the undersigned while participating in the : at Hospital unless such injury or loss arises solely out of gross negligence or willful misconduct. the Signature of Program Sergeline Name Dagun Date Parent or Legal Guardian Date If Program Participant is under 18 Print Name Doing My Part Personal Security 16. I will only access or use systems or devices I am authorized to access, and will not demonstrate the operation or function of systems or devices to unauthorized individuals. 17. I will not attempt to pass Company security controls. 18. I understand that I will be assigned a unique identifier (i., User ID) to track my access and use of Company systems and that the identifier is associated with my personal data provided as part of the initial periodic credentialing employment verification. 19. In connection with my Engagement, I will never: a. disclose or share user credentials (e., password, SecurID card, Tap n Go badge, etc.), PINs, access codes, badges, or door lock b. use another or allow another individual to use my, user credentials (e., User ID and password, SecurID card, Tap n Go badge, etc.) to access or use a Company computer system or C. allow a individual to access a secured area (e., hold the door open, share badge or door lock codes, prop the door d. use tools or techniques to break, circumvent or exploit security e. connect unauthorized systems or devices to the Company or f. use software that has not been licensed and approved the Company. 20. I will practice good workstation security measures such as locking up media when not in use, using screen savers with passwords, positioning screens away from public view, and physically securing workstations while traveling and working remotely. 21. I will immediately notify my manager, Facility Information Security Official (FISO), Director of Information Security Assurance (DISA), Facility Privacy Official (FPO), Ethics and Compliance Officer (ECO), or Facility or Corporate Client Support Services (CSS) help desk or if involving the United Kingdom, the Data Protection Officer (DPO), Information Governance Manager, Caldicott Guardian, Heads of Governance (HoG), Division Chief Information Security Officer (CISO) if: a. my user credentials have been seen, disclosed, lost, stolen, or otherwise b. I suspect media with Confidential Information has been lost or C. I suspect a virus or malware infection on any d. I become aware of any activity that violates this Agreement or any Company privacy or security or e. I become aware of any other incident that could possibly have any adverse impact on Confidential Information or Companysystems. Upon Separation 22. I agree that my obligations under this Agreement will continue after termination or expiration of my access to Company systems and Company Information. 23. At the end of my Engagement with the Company for any reason, I will immediately: a. securely return to the Company any Confidential Information, Company related documents or records, and Company owned media (e., smart phones, tablets, CDs, thumb drives, external hard drives, etc.). I will not keep any copies of Confidential Information in any format, including and b. any owned devices from the Company Enterprise Mobility Management System, if applicable. Except to the Extent Otherwise Agreed in a Separate Agreement, the Following Statements Apply to All Workforce Members 24. I shall promptly disclose to the Company all Company Property that I develop during my Engagement. means any subject matter (including inventions, improvements, designs, original works of authorship, formulas, processes, compositions of matter, software, databases, confidential information and trade secrets), whether belonging to the Company or others, that, directly or indirectly: (i) I author, make, conceive, first reduce to practice, or otherwise create or develop, whether alone or with others using any Company equipment, supplies, facilities, or Confidential Information, or (ii) otherwise arises from work performed me for the Company, its employees, or agents, (each of the foregoing. a 25. As between me and the Company, all Company Property is the property of the Company or its designee, and all copyrightable Developments that I create within the scope of my employment are made for 26. I agree to assign, and do here irrevocably assign, to the Company or its designee all of my right, title, and interest in and to any and all Developments, together with all intellectual property and other proprietary rights therein or arising therefrom, including any registrations or applications to register such rights and the right to sue for past, present, or future infringements or misappropriations thereof. 27. During and after my Engagement, I agree to execute any document and perform any act to effectuate, perfect, enforce, and defend the rights in any Development. I here appoint the Company and its authorized agent(s) as my attorney in fact to execute such documents in my name for these purposes, which power of attorney shall be coupled with an interest and shall be irrevocable, if fail to execute any such document within five (5) business days. 28. If there is a conflict between a term in Sections 24 through 28 and a term separately agreed to in writing with the Company, the term set forth in the separate agreement will control. signing this document, I acknowledge that I have read and understand this Agreement, and I agree to be bound and comply with all the representations, terms and conditions stated herein. Signature of Date Printed Name ID Sergeline Daguim Doing My Part Personal Security 16. I will only access or use systems or devices I am authorized to access, and will not demonstrate the operation or function of systems or devices to unauthorized individuals. 17. I will not attempt to pass Company security controls. 18. I understand that I will be assigned a unique identifier (i., User ID) to track my access and use of Company systems and that the identifier is associated with my personal data provided as part of the initial periodic credentialing employment verification. 19. In connection with my Engagement, I will never: a. disclose or share user credentials (e., password, SecurID card, Tap n Go badge, etc.), PINs, access codes, badges, or door lock b. use another or allow another individual to use my, user credentials (e., User ID and password, SecurID card, Tap n Go badge, etc.) to access or use a Company computer system or C. allow a individual to access a secured area (e., hold the door open, share badge or door lock codes, prop the door d. use tools or techniques to break, circumvent or exploit security e. connect unauthorized systems or devices to the Company or f. use software that has not been licensed and approved the Company. 20. I will practice good workstation security measures such as locking up media when not in use, using screen savers with passwords, positioning screens away from public view, and physically securing workstations while traveling and working remotely. 21. I will immediately notify my manager, Facility Information Security Official (FISO), Director of Information Security Assurance (DISA), Facility Privacy Official (FPO), Ethics and Compliance Officer (ECO), or Facility or Corporate Client Support Services (CSS) help desk or if involving the United Kingdom, the Data Protection Officer (DPO), Information Governance Manager, Caldicott Guardian, Heads of Governance (HoG), Division Chief Information Security Officer (CISO) if: a. my user credentials have been seen, disclosed, lost, stolen, or otherwise b. I suspect media with Confidential Information has been lost or C. I suspect a virus or malware infection on any d. I become aware of any activity that violates this Agreement or any Company privacy or security or e. I become aware of any other incident that could possibly have any adverse impact on Confidential Information or Companysystems. Upon Separation 22. I agree that my obligations under this Agreement will continue after termination or expiration of my access to Company systems and Company Information. 23. At the end of my Engagement with the Company for any reason, I will immediately: a. securely return to the Company any Confidential Information, Company related documents or records, and Company owned media (e., smart phones, tablets, CDs, thumb drives, external hard drives, etc.). I will not keep any copies of Confidential Information in any format, including and b. any owned devices from the Company Enterprise Mobility Management System, if applicable. Except to the Extent Otherwise Agreed in a Separate Agreement, the Following Statements Apply to All Workforce Members 24. I shall promptly disclose to the Company all Company Property that I develop during my Engagement. means any subject matter (including inventions, improvements, designs, original works of authorship, formulas, processes, compositions of matter, software, databases, confidential information and trade secrets), whether belonging to the Company or others, that, directly or indirectly: (i) I author, make, conceive, first reduce to practice, or otherwise create or develop, whether alone or with others using any Company equipment, supplies, facilities, or Confidential Information, or (ii) otherwise arises from work performed me for the Company, its employees, or agents, (each of the foregoing. a 25. As between me and the Company, all Company Property is the property of the Company or its designee, and all copyrightable Developments that I create within the scope of my employment are made for 26. I agree to assign, and do here irrevocably assign, to the Company or its designee all of my right, title, and interest in and to any and all Developments, together with all intellectual property and other proprietary rights therein or arising therefrom, including any registrations or applications to register such rights and the right to sue for past, present, or future infringements or misappropriations thereof. 27. During and after my Engagement, I agree to execute any document and perform any act to effectuate, perfect, enforce, and defend the rights in any Development. I here appoint the Company and its authorized agent(s) as my attorney in fact to execute such documents in my name for these purposes, which power of attorney shall be coupled with an interest and shall be irrevocable, if fail to execute any such document within five (5) business days. 28. If there is a conflict between a term in Sections 24 through 28 and a term separately agreed to in writing with the Company, the term set forth in the separate agreement will control. signing this document, I acknowledge that I have read and understand this Agreement, and I agree to be bound and comply with all the representations, terms and conditions stated herein. Signature of Date Printed Name ID Sergeline Daguim EXHIBIT C Attestation of Satisfactory Background Investigation On behalf of Galen College of Volunteer Organization, School, Contract Services Entity, or Staffing I acknowledge and attest to HCA that we own, and have in our possession, a background investigation report on the individual identified below. Such background investigation is satisfactory in that it: verifies the Social Security Number does not reveal any criminal confirms the individual is not on either the GSA or OIG exclusion confirms the individual is not on a State exclusion list, if confirms the individual is not listed as a violent sexual confirms this individual is not on the U. Treasury Office of Foreign Assets Control list of Specially Designation and no other aspect of the investigation required Hospital reveals information of and This attestation is provided in lieu of providing a copy of the background investigation. Identified Individual Subject to the Background Investigation: Name: Sorgeline Daguin Address: 8419 Sw 22ND St, Miramar FL 33025 Date of Birth: Social Security Number: 7901 Signature Printed Name of Date: EXHIBIT C Attestation of Satisfactory Background Investigation On behalf of Galen College of Volunteer Organization, School, Contract Services Entity, or Staffing I acknowledge and attest to HCA that we own, and have in our possession, a background investigation report on the individual identified below. Such background investigation is satisfactory in that it: verifies the Social Security Number does not reveal any criminal confirms the individual is not on either the GSA or OIG exclusion confirms the individual is not on a State exclusion list, if confirms the individual is not listed as a violent sexual confirms this individual is not on the U. Treasury Office of Foreign Assets Control list of Specially Designation and no other aspect of the investigation required Hospital reveals information of and This attestation is provided in lieu of providing a copy of the background investigation. Identified Individual Subject to the Background Investigation: Name: Sorgeline Daguin Address: 8419 Sw 22ND St, Miramar FL 33025 Date of Birth: Social Security Number: 7901 Signature Printed Name of Date: 9:45 PM HCA Healthcare EFD Competency Assessment: Student Orientation Essentials HCA Healthcare EFD Competency Assessment: Student Orientation Essentials Points: 1. Name (First and Last) SERGELINE DAQUIN 2. Name of Academic Institution GALEN COLLEGE OF NURSING 3. Date Correct Points 9:45 PM HCA Healthcare EFD Competency Assessment: Student Orientation Essentials HCA Healthcare EFD Competency Assessment: Student Orientation Essentials Points: 1. Name (First and Last) SERGELINE DAQUIN 2. Name of Academic Institution GALEN COLLEGE OF NURSING 3. Date Correct Points 9:45 PM HCA Healthcare EFD Competency Assessment: Student Orientation Essentials 4. As long as I have access, it is okay to take a peak at a chart during my clinical rotation False True Correct Points 5. Protecting PHI is required law and safeguarding it is responsibility. False True Correct Points 6. A sentinel event is a patient safety event that reaches a patient and results in which of the following. Select all that apply Death Severe temporary harm Near miss Widespread pandemonium Permanent harm Correct Points 7. individual shall be discriminated against on the basis of disability in the full and equal enjoyment of the goods, services, facilities, privileges, advantages, or accommodation any person who owns, leases, or operates a place of public This is known as the 9:45 PM HCA Healthcare EFD Competency Assessment: Student Orientation Essentials 4. As long as I have access, it is okay to take a peak at a chart during my clinical rotation False True Correct Points 5. Protecting PHI is required law and safeguarding it is responsibility. False True Correct Points 6. A sentinel event is a patient safety event that reaches a patient and results in which of the following. Select all that apply Death Severe temporary harm Near miss Widespread pandemonium Permanent harm Correct Points 7. individual shall be discriminated against on the basis of disability in the full and equal enjoyment of the goods, services, facilities, privileges, advantages, or accommodation any person who owns, leases, or operates a place of public This is known as the 9:45 PM HCA Healthcare EFD Competency Assessment: Student Orientation Essentials Face Shield All of the above Correct Points 11. The number one way to prevent the spread of infection is through hand hygiene. When washing hands with warm soap and water, and applying hand sanitizer, the minimum time for effective hand hygiene is seconds. 30 10 15 20 Correct Points 12. Notification of abuse neglect for children and vulnerable adults is optional and consent must be obtained prior to reporting True False Correct Points 13. The HCA Code of Conduct provides guidance to ensure our work is done in an ethical and legal manner False True 9:45 PM HCA Healthcare EFD Competency Assessment: Student Orientation Essentials Face Shield All of the above Correct Points 11. The number one way to prevent the spread of infection is through hand hygiene. When washing hands with warm soap and water, and applying hand sanitizer, the minimum time for effective hand hygiene is seconds. 30 10 15 20 Correct Points 12. Notification of abuse neglect for children and vulnerable adults is optional and consent must be obtained prior to reporting True False Correct Points 13. The HCA Code of Conduct provides guidance to ensure our work is done in an ethical and legal manner False True 9:45 PM HCA Healthcare EFD Competency Assessment: Student Orientation Essentials Correct Points 14. HCA is committed to the care and improvement of human life, above all else True False Correct Points 15. All HCA facilities use the acronym AIDET to help us remember key points for building trust and confidence in patients, visitors, and colleagues. AIDET stands for: Ask, Interest, Distinguish, Explain, Thanks Acknowledge, Introduce, Duration, Explanation, Thank you Acknowledge, Introduce, Discuss, Entertain, Trust Correct Points 16. SAFETY Rounding is a reliable nursing care delivery system that reduces variance, increases efficiency, and establishes safety, quality, and experience. SAFETY Rounds are to be performed : Nurses All team members entering patient rooms Nurse Leaders Environmental Services Lab 9:45 PM HCA Healthcare EFD Competency Assessment: Student Orientation Essentials Correct Points 14. HCA is committed to the care and improvement of human life, above all else True False Correct Points 15. All HCA facilities use the acronym AIDET to help us remember key points for building trust and confidence in patients, visitors, and colleagues. AIDET stands for: Ask, Interest, Distinguish, Explain, Thanks Acknowledge, Introduce, Duration, Explanation, Thank you Acknowledge, Introduce, Discuss, Entertain, Trust Correct Points 16. SAFETY Rounding is a reliable nursing care delivery system that reduces variance, increases efficiency, and establishes safety, quality, and experience. SAFETY Rounds are to be performed : Nurses All team members entering patient rooms Nurse Leaders Environmental Services Lab 9:45 PM HCA Healthcare EFD Competency Assessment: Student Orientation Essentials False Correct Points 21. Examples of include: Yellow armband Yellow sign outside door Bed in low position Frequent rounding Bed Alarm Prompt response to call light Frequently toileting All of the above X Incorrect Points 22. Protected Health Information (PHI) includes all of the following, except: (select all that apply) name Detailed description of tattoo or scar Year of birth Vehicle License Number Name, Address, Phone Number 9:45 PM HCA Healthcare EFD Competency Assessment: Student Orientation Essentials False Correct Points 21. Examples of include: Yellow armband Yellow sign outside door Bed in low position Frequent rounding Bed Alarm Prompt response to call light Frequently toileting All of the above X Incorrect Points 22. Protected Health Information (PHI) includes all of the following, except: (select all that apply) name Detailed description of tattoo or scar Year of birth Vehicle License Number Name, Address, Phone Number 9:45 PM HCA Healthcare EFD Competency Assessment: Student Orientation Essentials Correct Points 23. What is HITECH? Select all that apply A law that increased penalties for privacy and security violations A law guaranteeing the privacy and security of health information The Health Information Technology for Economic and Clinical Health Act A law that made massive changes to previously existing privacy and security laws A law created to protect health insurance coverage and access to health care Go back to thank you page This content is created the owner of the form. The data you submit will be sent to the form owner. Microsoft is not responsible for the privacy or security practices of its customers, including those of this form owner. Never give out your password. Powered Microsoft Forms The owner of this form has not provided a privacy statement as to how they will use your response data. Do not provide personal or sensitive information. Terms of use 9:45 PM HCA Healthcare EFD Competency Assessment: Student Orientation Essentials Correct Points 23. What is HITECH? Select all that apply A law that increased penalties for privacy and security violations A law guaranteeing the privacy and security of health information The Health Information Technology for Economic and Clinical Health Act A law that made massive changes to previously existing privacy and security laws A law created to protect health insurance coverage and access to health care Go back to thank you page This content is created the owner of the form. The data you submit will be sent to the form owner. Microsoft is not responsible for the privacy or security practices of its customers, including those of this form owner. Never give out your password. Powered Microsoft Forms The owner of this form has not provided a privacy statement as to how they will use your response data. Do not provide personal or sensitive information. Terms of use
Galen Clinical Documents
Course: Fundamentals (NUR155)
University: Galen College of Nursing
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