Shadowing Request Form

Shadowing Request Form
Please read and complete the entire application form. When complete, we will contact you for scheduling. Note: Shadowing is generally a one-time (up to 8 hours), hands-off experience, and it may take several months to find an available time based on schedules and provider availability.

*This form cannot be saved and must be completed all at once. Please have vaccine records ready before beginning. Required vaccines and health documentation can be found below. *NOTE: Current LMH employees and active LMH volunteers do not need to upload any vaccine records as we already have these records on file*
This shadowing experience is not intended for those students seeking a clinical rotation or internship required by their educational program. Observation experiences/shadowing are for exploration and/or experience in the healthcare field. If you are seeking a clinical rotation or internship please contact students@lmh.org
Please note: Letters of reference from a provider following a one-time shadowing experience are not applicable to this program.
Immunization Requirements:

I understand that for my safety and the safety of the patients in this healthcare setting, it is important for me to submit the following health history information.

It is required that you upload documentation as proof of the following immunizations. Current LMH employees and active LMH volunteers do not need to upload the following items.

Only applications with complete immunization records will be considered for shadowing experiences at LMH Health. Please ensure your records include all required immunizations or complete the required immunizations before uploading this application.
- TB (Tuberculosis) Screening- READ CAREFULLY AND DO NOT SUBMIT BEFORE HAVING THESE RESULTS! Provide documentation of the following:One Blood Test (Quantiferon Gold or TSPOT IGRA) within the last 12 months OR Two TB skin tests (two injections and two readings) within the last 12 months. The 2nd skin test must be placed and read no sooner than 1 week and no later than 3 weeks after the 1st skin test. Copy of chest x-ray results must be provided if you tested positive to TB to rule out active disease.
- Influenza: Documentation required during flu season as determined by LMH Health.
- Tetanus/diphtheria/acellular pertussis (Tdap): adult formulation-Adacel or Boostrix (administered after 2005)
- Hepatitis B vaccinations: Proof of the 3 shot Hepatitis B series or proof of immunity (Positive Hepatitis B titer).
- Chicken pox (Varicella): Two (2) varicella vaccines, at least 28 days apart Or Serological proof of immunity (positive varicella IGG titers)
- MMR: Two (2) MMR vaccinations at least 28 days apart Or serological proof of immunity (positive IGG titers for each)
Please sign below to indicate your understanding of the health requirements for the shadowing program at LMH Health:

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Name

First NameLast Name
Birthdate

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Semester I am applying for (fall, spring, summer):
Current University/Program
Current Year in school
Cumulative GPA
Current Program/Major or Degree
Have you ever worked at LMH before?
Dates of LMH Employment/Department:
Have you ever volunteered at LMH before?
Dates of service and areas you volunteered:
Emergency Contact; please provide name, relationship to participant and contact number:
Area of Interest or Dept/Clinic to shadow: (Please note there are currently several departments not accepting shadowing students)
Name of Practitioner or Staff Member who have agreed to shadowing (if known)
Please select your observation experience objective (choose one)
If Other please explain:
Please provide a brief statement describing what you hope to gain from this experience.
Please provide required vaccination records here. Please read the above TB test requirements carefully before submitting:

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I understand that despite all reasonable safety precautions, healthcare environments present a risk of exposure to communicable diseases. I agree to abide by the Standard Precautions procedures. If I am pregnant or think I might be, I agree to inform the person supervising my observation BEFORE I begin my experience at LMH Health.

I understand that emergency medical assistance is available if needed but that I am responsible for any related expenses and for my own health insurance.

In consideration for the opportunity to complete my experience at LMH Health, I hereby release LMH Health, its officers, directors, employees, and agents from any claim, damage or liability related to my experience at LMH Health.
By initialing here, I understand the above statement:
I agree to comply with hospital dress code. With the exception of scrubbing in to observe a surgery, I agree to wear professional clothing during my observation at LMH Health or an affiliated site. This includes slacks, a nice top, and closed-toe shoes. I understand that I may be sent home to change or my observation time could be cancelled if I arrive wearing improper attire.
By initialing here, I understand the above hospital dress code statement:
LMH Health is committed to the safety of our patients and personnel. These safety guidelines are provided to outline your role and responsibilities while observing patient care and processes.

These are LMH safety codes pages in response to emergencies or unusual incidents, as well as your responsibilities. If you are the first person to encounter any of these situations, pick up the nearest hospital phone and dial 6400 to notify the operator of your location and the situation.
- Code Blue: a person is not breathing and has no pulse. If you notice this, get the patient's nurse IMMEDIATELY.M.E.T. or Medical Evaluation Team. MET responders rapidly assemble in response to acute clinical deterioiration before cardiopulmonary arrest offers.
- Code Red: Fire! If you see one, Rescure the patient from the fire, pull the Alarm, Contain the fire (fire doors will close), and Evacuate the area. If you hear this page, ask LMH staff for instructions.
- Amber Alert:Infant/Child Abduction. Stay with the person you are observing. LMH Security and/or other law enforcement will respond.Code Yellow: Emergency Prepardeness Plan is in effect. Ask LMH staff for instructions.
- Code Orange: Hazardous Material Contamination. Stay with the person you are observing and ask for instructions.Evacuate. Evacuate a unit or building. Stay with the person you are observing and ask for instructions.
- Code Gray: A person is a threat to self or others. Stay with the person you are observing and ask for instructions.
- Active Shooter: Hostile situation with a weapon. Call 911. Do NOT enter the area. Secure the area pending the arrival of Security or Law Enforcement.
- Bomb Threat: Notify Security of any suspicious call or items by calling on any LMH phone 3604.
- Clear: The situation has been cleared. Operations return to normal status
- Severe Weather Watch or Warning: Stay with the person you are observing and ask for instructions.
- Report any unsafe conditions (such as spills, fire hazards, trip or fall hazards, etc.) immediately to LMH staff.
By initialing here, I have reviewed the above safety information:
Interacting with Patients and Confidentiality:

As an observer, you will NOT have any hands-on contact with patients. Recognize that each patient has unique needs, likes, dislikes, values, beliefs, and experiences. Persons from different cultures may have unique views about healthcare practices, personal relationships, language and communication styles, verbal and nonverbal communication, food preferences, religion, views about birth and death, and economic needs.

Your observation experience will bring you into contact with patient records and information or place you in a position to hear discussions of patient care. Any information you see or hear concerning a patient's diagnosis, condition, treatment, financial, or personal status is STRICTLY CONFIDENTIAL. Patients desiring privacy are to be granted privacy. Personnel who discuss the presence of a particular patient at LMH Health may be violating that right of privacy.

For this reason, you are not to discuss, either inside or outside the hospital or on the internet, the identity or condition of any patient with anyone not directly concerned with their care. You may discuss such information only with staff as directly related to your observation experience. Medical information should never be disclosed to anyone. A breach of these rules violates hospital and medical ethics and could have legal consequences for both you and the hospital.
By initialing here, I agree to maintain patient confidentiality.
Infection Prevention:

I agree to follow all LMH Health guidelines and protocols related to infection prevention, including but not limited to:
- Wearing a mask as mandated by LMH Health, along with any other personal protective equipment as required in the area of observation, such as face shields, goggles, gloves, etc.
- Regular and thorough hand hygiene. Do it before and after your observation shift, before and after entering and exiting patient or treatment rooms, before and after eating or toileting, and after sneezing or coughing.
By initialing here, I understand the above infection prevention statement:
I understand that my observation experience at LMH Health and its affiliated clinics will be short-term, based on the availability of the provider(s) and putting patient care and patients' needs first and foremost.

I agree to conform to all organizational policies and procedures during the time I spend at LMH Health. I agree to take direction from the LMH Health staff.

I understand that for the security of patients and staff, LMH Health identification must be worn at all times. A shadowing ID badge must be obtained prior to the start of the observation experience.
By initialing here, I understand the above statement and will contact Volunteer Services to arrange to receive my shadowing badge prior to the start of my observation experience.
Applicant Acknowledgement: I understand that staff are being generous with their time in allowing me to shadow. I will be punctual and conscientious in the fulfillment of my observation experience and accept supervision graciously. I will conduct myself with professionalism, responsibility, integrity, dedication, and excellence.

I will endeavor to make my experience and contribution at LMH Health of the highest quality and uphold the traditions and standards of this organization.

All the information I have provided is true. I understand that any false statement or material omission will impact my ability to start and/or keep observing with staff.
By signing my name below, I understand and agree to all rules and regulations at LMH Health.

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By initialing here, I verify completion of the Online Orientation linked below.
Please complete the Online Orientation found at this link:

https://www.canva.com/design/DAGAtwH2q3U/KJlRfQz0wtnKPd-WS9zXhg/view?utm_content=DAGAtwH2q3U&utm_campaign=designshare&utm_medium=link&utm_source=editor
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Shadowing Request Form

Please read and complete the entire application form. When complete, we will contact you for scheduling. Note: Shadowing is generally a one-time (up to 8 hours), hands-off experience, and it may take several months to find an available time based on schedules and provider availability.

Please note: Letters of reference from a provider following a one-time shadowing experience are not applicable to this program.