Good Samaritan considers it a privilege to share knowledge. Our mission is to provide you the opportunity to gain insight into your field of interest while building lasting, trusting relationships.

We are excited that you are interested in shadowing at Good Samaritan. We are a world-class facility and we are proud to share that with you. In preparation for your rotation and to start our shadowing process, information is required from you. Please complete and return the following attached forms and/or documentation.

Some of this information is personal, so we use a system that protects your information, allowing access to only those involved in preparing your rotation. We will need a copy of your immunization record. Please be prompt in getting these requirements to the email listed below. Any missing or incomplete documentation could result in delay/denial of shadowing request. However, feel free to contact us with questions.

I understand that I cannot start shadowing at Good Samaritan until all requirements are submitted and approved. I must submit my observation and times to the CIE staff prior to approval. Failure to do so could result in the termination of my clinical experience.

By selecting "I Agree" below, you acknowledge that this action constitutes your digital signature and signifies your acceptance of the terms and conditions.

I acknowledge that I have received a copy of the “Special Staff, Student, and Volunteer Handbook,” and have read and understand all listed provisions.

I agree to adhere to all Good Samaritan policies, procedures, and provisions set forth in the Handbook related to general and electrical safety, incident reporting, infection control, waste disposal, confidentiality, emergency conditions and response, patient rights, diversity, and staff rights (if applicable). For further reference, I will find policy and procedure manuals in each unit or department to which I am assigned.

I agree to provide Good Samaritan with written training and safety records upon request. I agree to contact the Infection Preventionist and/or Coordinator at Good Samaritan prior to assuming work activities if I have had recent contact with an individual with active tuberculosis or diseases such as chicken pox or rubella. I will contact the Infection Preventionist and/or Coordinator prior to assuming work activities if I have had persistent productive cough of two weeks or longer, night sweats, fever, or open skin lesions. Following orientation, if I have questions regarding the provisions in the “Special Staff, Student, and Volunteer Handbook,” I may ask the supervisor of the unit or department to which I am assigned.

I have read, understand, and have received a copy of the Good Samaritan guidelines related to confidential patient information. I realize that there are civil and criminal penalties for the unauthorized use and disclosure of confidential patient information. I will abide by the guidelines when completing my clinical or observation rotation.

Good Samaritan requires all caregivers to acknowledge that they received the Code of Conduct. The Code represents mandatory standards of conduct acceptable at Good Samaritan. New caregivers and providers are required to submit their acknowledgment through the new hire process as a condition of employment.

Responsibility
Violations of this Code of Conduct and Good Samaritan policies and procedures can lead to disciplinary action up to and including termination. Conduct that violates the law also may result in civil and criminal penalties ranging from fines to imprisonment.

Reporting
Individuals affiliated with Good Samaritan have a responsibility to report any suspected or actual violation of the Code of Conduct or other policy irregularities to any member of management, the Human Resources Department or the Compliance Officer. For those who wish to remain anonymous, the report may be submitted by calling the Compliance Hotline.

I acknowledge that:

• I have received the Good Samaritan Code of Conduct and understand that it is my responsibility to read and comply with the legal and ethical practices contained in the Code of Conduct.
• I must report potential compliance issues to a supervisor, to the Human Resources Department, the Compliance Officer or the Compliance Hotline.
• I am aware that violations of the Code of Conduct and Good Samaritan policies and procedures may result in action that addresses my behavior.

I hereby confirm that I have received a copy of the “Risk Management Safety Information Handbook for Non-Hospital Personnel”.

I agree to adhere to the expectations set forth in the “Risk Management Safety Information Handbook for Non-Hospital Personnel”.

I also agree to adhere to Good Samaritan’s policies/procedures and emergency alert responses. Policies/procedures will be available to each department.

I hereby confirm that I am a bona fide authorized agent of the business or agency that I am representing.

 

I have previously received the training/instruction needed to perform the work assigned by my company/agency while at Good Samaritan.

I agree to provide Good Samaritan with written training and safety records upon request.

I agree to contact Infection Prevention at Good Samaritan prior to assuming work activities if I have had recent contact with an individual with active tuberculosis or diseasessuch as chickenpox or rubella. I will contact Infection Prevention prior to assuming work activitiesif I have had a persistent productive cough of two weeks or longer, nightsweats, fever, or open skin lesions.

I understand that if I have questions regarding the “Risk Management Safety Information Handbook for Non-Hospital Personnel” I may contact Risk Management. Other contacts are the Department Director or Manager, and the Nursing Supervisor.

Payment for Products:
I understand that any invoices submitted for products that have not been properly presented to GS, as described in GS policy #P16.05, will not be paid.
I understand that in the course of my work I may come in contact with confidential information, including clinical, employee-related, financial, and administrative. Such information may be acquired from written records, documents, ledgers, internal verbal correspondence and communication and computer programs and applications.

I understand that unauthorized use of computer terminals/workstations for any purpose is prohibited and that any non-hospital person who accesses or attempts to access computer information that is not within his/her scope of responsibility will be subject to termination from the hospital.

I understand that all information obtained by virtue of my work in the hospital must be held in the strictest confidence. I agree not to divulge or disclose to anyone other than those persons in the hospital who have the “need to know” directly or indirectly, any confidential information acquired during the course of my work at Good Samaritan. I understand that my obligations under this Agreement will continue after termination of my non-hospital personnel status.

I understand and acknowledge that in the event I breached any provision of this
Agreement. Good Samaritan has the right to terminate my non-hospital personnel status.

Do you currently have any of the following?

If you answered “Yes” to any of the above questions, the Infection Prevention Coordinator will be contacting you for further information.

I understand that my child will be signing forms indicating his/her agreement to abide by Good Samaritan’s policies, procedures and confidentiality guidelines.

The signature page and confidentiality agreement is to be signed during the safety education process prior to assuming work activities.

The original signature page and confidentiality agreement will be sent to the Collaborative Interprofessional Education Department where it will be placed on file.

A copy of the signature page and confidentiality agreement will be retained and filed by the Department Director or their delegate.