Student Observation Request Form
Full Name
First Name
Last Name
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I would like to request to observe the following
Physical Therapy
Occupational Therapy
Speech Therapy
Other
I am a
High School Student
Undergraduate College Student Deciding on Career
Undergraduate College Student Applying to Graduate School
Number of Hours Requesting:
Days and TIme Requested:
The Federal Health Insurance Portability and Accountability Act (HIPAA) and related laws and regulations were established to preserve the confidentiality of medical and personal information, and to specify that such information may not be disclosed except as authorized by law or unless authorized by the patient. These privacy laws and regulations apply to all Achieve Health and Wellness personnel including students. All students are required to agree to and sign this confidentiality statement.
I agree
I understand that, as an observer for clinical education purposes at Get Set Grow Therapies, LLC, I may see or hear confidential information (such as, but not limited at Achieve Health and Wellness, I may see or hear confidential information (such as, but not limited to: medical information, medical history, radiological reports, daily treatment information, etc.) about a patient, verbal discussions about patient care, and electronic communications that include confidential patient information.
I agree
I acknowledge that it is my responsibility to respect the privacy and confidentiality of this information. I will not access, use, or disclose any confidential information outside of my educational experience at Achieve Health and Wellness. I understand that I am required to immediately report any information I may have about the unauthorized access, use, or disclosure of confidential information to the Achieve Health and Wellness Clinic
I agree
I understand that if I breach any provision of this Agreement, I may be subject to civil and/or criminal liability.
I agree
Name
Signature
Date
-
Month
-
Day
Year
Date
*(If student is under 18 years of age, then parent/guardian signature is needed as well.) I am the parent/guardian of the student named above and I agree to be responsible for my Child’s inappropriate access, use, or disclosure of confidential information during his/her Participation at Get Set Grow Therapies, LLC. Participation at Achieve Health and Wellness
I am 18 years old or older
I am under 18 years of age, and parent/guardian signature is required
Parent/Guardian Name
Signature
Date
-
Month
-
Day
Year
Date
Dress Code: What we wear to work is a reflection of the pride we have in our Company, in what we do, and in ourselves. Although dress code requirements will vary according to job responsibilities, we ask that your appearance at all times show discretion, good taste, and appropriateness. Office staff are asked to dress professionally. Athletic/workout apparel, casual shorts, spaghetti string clothing, or casual t-shirts (unless GSG apparel) are not permitted. No mid-drifts, short skirts, or any clothing that is revealing is not acceptable. Appropriately fitting jeans without holes are permitted. Therapy staff are asked to wear scrub pants and scrub tops or professionally designated tops, athletic tops, or GSG apparel. Appropriately fitting jeans without holes are permitted. Tshirts with writing other than related to therapy services are not permitted unless approved ahead of time (Holiday theme, etc.). Please remember that you are working in a physically active environment. Please dress conservatively and in a way that you are able to move within your space while maintaining your appearance. If you are in doubt, please ere on the conservative side. If there is a violation you may be asked to leave and return in appropriate attire. Prohibited Tattoos and Body Piercings: No visible tattoos are allowed above the shoulders (excluding tattoos for natural looking cosmetic enhancements, such as eyebrows, lips, and eye liners). Visible tattoos on other body parts that are perceived by management as distracting for the facility and client pediatric environment may need to be covered in the workplace. Tattoos that contain offensive words, messages, slogans, or pictures, including but not limited to those displaying nudity, sexual acts, gender, race, religion, disability, or national origin, and/or may be perceived to be gang-related shall be covered and/or not visible while on duty. Objects, articles, jewelry (including ear lobe expanders), or ornamentation of any kind shall not be inserted, attached to or through the skin if visible on the tongue, any part of the mouth, or cheek. Two (2) sets of reasonably-sized earrings may be worn in each ear lobe. A single (1) stud may be displayed in one (1) nose. Any non-conforming piercing insert shall be removed, covered, or replaced with a clear insert.
I have read and will abide by all policies.
Safety Policy: Accordingly, the Company emphasizes "safety first." It is the individual's responsibility to take steps to promote safety in the workplace and work in a safe manner. The Company is committed to providing its employees/students with a safe and productive work environment. In keeping with this commitment, it maintains a strict policy against the use of alcohol and the unlawful use of drugs in the workplace. Consequently, no individual may consume or possess alcohol, or use, possess, sell, purchase or transfer illegal drugs at any time while on the Company's premises or while using the Company vehicles or equipment, or at any location during work time. No employee/student may report to work with illegal drugs (or their metabolites) or alcohol in his or her bodily system.
I have read and will abide by all policies.
Cell Phone Policy: The use of personal cell phones at work is discouraged because it can interfere with work and be disruptive to others. Therefore, employees/students who bring personal cell phones to work are required to keep the ringer shut off or placed on vibrate mode when they are in the office, and to keep cell phone use confined to breaks and meal periods. When using the cell phone in a public place, please remember to maintain the confidentiality of any private or confidential business information.
I have read and will abide by all Cell Phone Use policies.
Name
First Name
Last Name
Signature
Date
-
Month
-
Day
Year
Date
This form will be submitted to our office, and someone will contact you. Thank you!
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