The maximum number of observation hours is 40, unless your school has a specific arrangement with our center.

An individual is considered to be from a disadvantaged background if he or she meets two or  more of the following criteria:  

• Were or currently are homeless.
• Were or currently are in the foster care system.
• Were eligible for the Federal Free and Reduced Lunch Program for two or more years.
• Have/had no parents or legal guardians who completed a bachelor’s degree.
• Were or currently are eligible for Federal Pell grants.
• Received support from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) as a parent or child.
• Grew up in one of the following areas: a) a U.S. rural area, as designated by the Health Resources and Services Administration (HRSA) Rural HealthGrants Eligibility Analyzer (https://data.hrsa.gov/tools/rural-health), or b) a Centers for Medicare and Medicaid Services‐designated Low‐Income and Health Professional Shortage Areas (qualifying zip codes are included in the file Only one of the two possibilities in #7 can be used as a criterion for the disadvantaged background definition.

Students obserserving more than 20 hours will need to provide an updated copy of their immunization records.

I agree to strive for excellence. In doing so I will demonstrate a desire to maintain a high level of patient and customer satisfaction at Comanche County Memorial Hospital. I have read and understand the CCMH standards of behavior and agree to abide by the standards as a condition of my observation experience at CCMH.

I further understand that patient and customer satisfaction is my responsibility, and I agree to take pride and ownership in the customer experience. In doing so I will regularly and consistently evaluate my attitude toward customer service to ensure that my personal actions are in line with the goals of CCMH.

I agree to use my talents, knowledge, skills, and abilities to positively impact the lives of CCMH customers. I will adopt the CCMH mission and vision statements and be a personal stakeholder in the success of the organization.

I understand that my observation experience at CCMH is contingent upon my willingness to uphold and abide by the CCMH standards of behavior.

Through my association with the Organized Health Care Arrangement (OHCA) as an employee, agent, independent contractor, volunteer, student, physician, or approved observer, I understand that patient information in any form
(paper, electronic, oral, etc.) is protected by law and that breaches of patient confidentiality can have severe ramifications up to and including termination of my relationship with the OHCA as well as possible civil and criminal penalties. I will only access, use or disclose the minimum necessary to carry out my assigned duties. I will not improperly divulge any information which comes to me through the carrying out of my assigned duties, program assignment or observation.

This includes but is not limited to:

• I will not discuss information pertaining to any patient with anyone (even my own family) who is not directly working with said patient unless for reasons of treatment, payment, or healthcare operations (TPO).
• I will not discuss any patient information in any place where it can be overheard by anyone who is not authorized to have this information unless for TPO.
• I will not mention any patient’s name or disclose directly or indirectly that any person is a patient except to those authorized to have this information unless for TPO.
• I will not describe any behavior which I have observed or learned about through association with this OHCA, except to those authorized to have this information unless for TPO.
• I will not contact any individual or agency outside this OHCA to get personal information about an individual patient unless a release of information has been signed by the patient or by someone who has been legally authorized by the patient to release information unless for TPO.
• I will not use confidential OHCA business related information in any manner not required by my job or disclose it to anyone not authorized to have or know it unless for TPO.

With my signature, I indicate I have read and understand this Acknowledgment.

 

This is to acknowledge that I have reviewed and agree to abide by Comanche County Hospital Authority Policy on Compliance, including the Code of Conduct. I understand that I have an obligation to report any activity which I have know or suspect may violate any provision of the CCMH Compliance Policy or the Code of Conduct. Any potential conflicts of interests (as defined by the Policy) of which I have knowledge are noted in the disclosure section below.

I have attended Comanche County Memorial Hospital’s student/non-employee orientation at which time infection control, HIPAA, safety, performance improvement and employee topics pertinent to hospital policy were presented.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under U77HP31121 Point of Service Maintenance and Enhancement, with an annual award and a 100% non-federal match.

The Oklahoma State University Center for Health Sciences prohibits discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibits discrimination against all individuals based on their age, race, color, religion, sex, sexual orientation, gender, gender identity, national origin or ethnicity.

As part of a federally sponsored HRSA program and in order to better serve students, the SW-AHEC program at Comanche County Memorial Hospital needs demographic and statistical information. Continued follow-up via phone and/or e-mail can occur. By signing this form, you give permission to have initial information as well as follow-up and further education information reported to the US Health Resources & Services Administration (HRSA.gov)

I understand that this information is confidential and may only be shared with Comanche County Memorial Hospital, HRSA, and the Oklahoma Area Health Education Center. I recognize that this information will not be released without consent unless required by state or federal laws.