As a student/resident, I understand that I may have access to confidential medical or business information, both clinical and employee related, through written records, documents, ledgers, internal verbal correspondence and communications, and computer programs and applications.

I agree not to divulge or disclose to anyone other than those persons of UK St. Claire who are identified by written policy as having the "need to know" directly or indirectly, either during and after my internship/med-student/resident experience, any confidential information acquired during the course of my experience. I understand and acknowledge that, in the event I breach any provisions of this agreement with UK St. Claire, and in addition to any other legal remedies available to them, has the right to reprimand, suspend, and/or terminate my education experience with or without notice at their discretion. By providing my digital signature below, I hereby agree to the conditions listed above.

I agree to return the security badge, badge and badge buddy which has been assigned to me for my use during my rotation at UK St. Claire. I further agree to pay the cost of the badge in the event that I should lose it, damage it or not return it, that cost will be $10.00. You may return badges to the AHEC office Monday – Friday from 7am – 4:30pm or we have a drop off box outside the door located on the 2nd floor of the hospital between HR and Employee Health.

Please make sure these are returned when you leave or we will have to contact your program coordinator.

As a student or resident of an agent of UK St. Claire, I have been provided access to the computer systems at UK St. Claire through one or more assigned user accounts and/or passwords. Records accessible to me may include confidential business and/or patient information. I understand that my account(s)/password(s)/user code(s) are for my use only and, as such, will not allow them to be used by any other person. My password may also serve as my legal signature to any information entered into the hospital's system.

Execution of this agreement and continued compliance with all of the promises and obligations herein are continuing conditions of receiving authorization for access to any information maintained by UK St. Claire.

I understand that, as a user of UK St. Claire information system, I may be granted access to certain information that is strictly confidential. I acknowledge this confidentiality and agree to maintain this information in strict confidence. I understand that confidential information includes but is not limited to, patient information, quality assurance and utilization review information, strategic planning, hospital operations information and computer password information.

Violation of this agreement will result in loss of access to hospital information systems and constitutes grounds for corrective action up to and including employment termination. Violation of this agreement or the policies of UK St. Claire constitute grounds for termination of any relationship between myself or my employer and UK St. Claire Unauthorized release of confidential information may also have civil and/or criminal penalties as specified in the Health Insurance Portability and Accountability Act of 1996, the Health Information for Technology for Economic and Clinical Health (HITECH) Act, or other such legislation.

I agree to the following stipulations regarding my access to UK St. Claire information:

1. I will access only the information that Is needed for the job that I am performing.

2. The information is to be used for the sole purpose of performing the duties if my job.

3. The information will not be disclosed, by me, to any person whatsoever, except in direct connection with the performance of my job.

4. Not to copy or reproduce, or permit any other person to copy or reproduce, in whole or in part, confidential information other than in the regular course of the services I am authorized and requested to perform for St. Claire Regional Medical Center.

5. To comply with all St. Claire Regional Medical Center policies regarding security of information.

6. To immediately report to the St. Claire Regional Medical Center Privacy Officer any unauthorized use, duplication, disclosure, and or dissemination of confidential information by any person, including me.

I understand that access to UK St. Claire computer system via sign-on code is recorded and I will not disclose this sign-on to anyone. I have read and understand the confidentiality policy of UK St. Claire

I agree to indemnify UK St. Claire fully for any and all damages, including legal fees that UK St. Claire may incur as a result of my intentional breach of this agreement. I further agree that upon termination of my work with UK St. Claire, for any reason, I will immediately return any documents containing any confidential information to UK St. Claire and, upon request, that I will certify in writing that all such documents and other media has been returned to UK St. Claire I understand that disclosure of any confidential Information may cause UK St. Claire irreparable harm, for which monetary compensation may not be an adequate remedy, and I agree that UK St. Claire may seek injunctive relief if I breach, or attempt to breach, this agreement.

I agree that all obligations under this confidentiality agreement shall survive termination of my employment/direct association with UK St. Claire, regardless of the reason for such termination.

I attest that I have read the information provided to me in the Student/Resident Orientation Overview literature.  I understand that I am responsible for the content in its entirety.  Furthermore, while on rotation at UK-St. Claire or any of its facilities,I will uphold the values and follow the guidelines for acceptable behavior as described in the overview literature. By signing below, I acknowledge I have read and understand all information in the Student/Resident Orientation Overview. I understand that I can be dismissed from clinical rotation should it be determined that I did not follow the guidelines or policies defined in the overview. I acknowledge I can be asked to leave UK-St. Claire immediately without cause. I have provided the Northeast KY AHEC and UK-St. Claire the information listed below and is required prior to reporting to my rotation site. Failure to provide any information listed below will result in not participating in the rotation.

The following documentation is required for all students rotating at UK St. Claire Healthcare:

• A Letter from the institution stating that the student/resident is in good standing
  • Letter must be addressed to Sue Russell or Cassie Chandler, Student Services Coordinator, typed on letterhead, include students name, rotations dates and signed by the one administering the letter
• Criminal/Caregiver background check that shows the student does not have any past history of drug abuse, felony, etc
• Drug screen results showing a negative
• Immunization and health records showing 2 MMR’s or titers drawn showing immunity, compliant with CDC recommendations
• Results from a two-step TB Skin Test is required and consistent with CDC guidelines for SCR. These are 2 separate tests with the second test administered within the last year of rotation start date and the first test administered within the last year of the second one. This type of testing is compliant with CDC recommendations for SCR. If you have never had a TB skin tests done, please allow at least a 2 week time frame for both tests to be administered before you start your rotation.
• Annual flu shot has been administered during the flu season time frame of October 1 – March 31. (Must provide a copy for SCR employee health reporting.)
• Professional Photo with a solid background, no accessories please.