Job Shadow - External Registration Form

Job Shadow - External Registration Form

Alberta Precision Laboratories (APL) is a wholly-owned subsidiary of Alberta Health Services (AHS).
It is the responsibility of the applicant to find their own host.

On our Job Shadow site Job Shadowing | Alberta Health Services under Application Information there is a link to "search for hospitals or facilities."

You may use this to contact a facility that you are interested in doing a job shadow with to find a host. You may also use other internet searches to contact a healthcare facility switchboard and be directed to a specific department or unit.

Ask to speak with the manager of the department or unit you are interested in. Managers are aware of the job shadow process and are encouraged to find hosts for interested applicants.

The job shadow participant will be required to Watch Video: AHSecure. Collect IT. Protect IT. Complete Online Learning Module: Information Privacy & IT Security Awareness

The manager will review signed AHS Confidentiality & User Agreement and email it to HRDataAdmin.AHS@ahs.ca

The job shadower’s immunization records will need to be reviewed by the host or manager to ensure the required Rubella vaccination. AHS does not retain a copy of these records.

Participant Information
Which organization are you requesting a Job Shadow with?*

Alberta Health Services (AHS)Alberta Precision Laboratories (APL)
Name*

First NameLast Name
Are you under the age of 18?*

YesNo
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Start Date Requested/Preferred*

YearMonthDay
Date
End Date Requested/Preferred*

YearMonthDay
Date
Comments (use this section to clarify dates or schedule if needed)
Total Number of Days Attending*
Job Shadow is generally a one (1) day observational experience that does not require a criminal record check. If the request extends beyond 5 business days a satisfactory criminal record check is required (within 90 days)

AHS/APL Employee Host Information
AHS/APL Employee Name*

First NameLast Name
AHS/APL Position Title*
AHS/APL Phone Number
Please enter a valid phone number.
Host Email (please ensure email is spelled correctly, and it is the best email to contact the host to approve this request)*
example@example.com
Department/Unit*
City*
Site/Facility (No abbreviations please)*
Zone*
Manager Name (or department delegate)*

First NameLast Name
Manage Email (please ensure email is spelled correctly and is the best email to contact the manager to approve this request )*
example@example.com

Job Shadow Attendance Agreement

AHS and APL supports opportunities for Job Shadow Participants to job shadow an AHS/APL host. As the healthcare environment may be unfamiliar, the Host and Manager must ensure that the Job Shadower is aware of and complies with the policies, directives and practices (together referred to as “rules”), such as confidentiality and safety.

Please read the following statements that are to be adhered to by all parties involved in the job shadow.

• I would like to participate in a Job Shadower at AHS/APL.

• I agree that it is my responsibility that the Job Shadower complies with all policies including confidentiality. The Host will explain to the Job Shadower that AHS/APL has a legal and ethical responsibility to safeguard the privacy of all patients/residents/clients and to protect the confidentiality of their personal information. My Job Shadower agrees to abide by the AHS/APL policies and procedures concerning confidentiality and release of information.

• I understand that all personal and health information the Job Shadower is privy to is private and confidential. The Job Shadower agrees not to discuss with anyone any individual’s identifying personal or health information that they may come into contact with while participating.

• I understand that I may be held responsible for any improper conduct of the Job Shadower, including but not limited to any breach of privacy or confidentiality.

• I agree that I will not hold AHS/APL liable or responsible for injury suffered to the Job Shadower while participating howsoever caused.

• I agree to indemnify AHS/APL for any loss that it may sustain as a result of the Job Shadowers participation.

• I understand that in order to participate in the program, the Job Shadower is required to have the Rubella vaccine (German Measles). It is also strongly recommended for the Job Shadower to have the following vaccinations and/or immunizations: Pertussis (Whooping Cough), Tetanus + Diphtheria, Measles, Mumps, Polio, Hepatitis B, Varicella (Chickenpox), Seasonal Influenza and Tuberculosis skin test.

The personal information on this form is collected under the legal authority of section 33(c) of the Freedom of Information and Protection of Privacy Act. The information will be used by or disclosed for employment purposes. For questions, concerns or more information about the collection, use or disclosure of the personal information, please contact Information and Privacy at 1-877-476-9874 or by email at privacy@albertahealthservices.ca

By signing below, the Job Shadower states that he/she understands the detailed content of this Agreement and the Manager and Employee (Host) will reviewed it with him/her.
I have read and understand this Agreement. I agree with the terms of this Agreement and confirm my agreement by signing in the space below. I am aware that by signing this Agreement I am waiving certain legal rights, including the right to sue, which I, my child and our respective heirs, next of kin, representatives and assignees may have against AHS/APL and/or Releasees.
Job Shadow Participant Signature*

Clear
Date*

MonthDayYear
Date
Parent/Guardian (if under 18 years of of age)

Clear
Should be Empty:

Job Shadow - External Registration Form

Participant Information

AHS/APL Employee Host Information