Holy Cross - SLC Intubation Waiver

Holy Cross - SLC Intubation Waiver
EXHIBIT A

STATEMENT OF RESPONSIBILITY
For and in consideration of the benefit provided the undersigned in the form of experience in evaluation and treatment of patients Salt Lake Regional Medical Center, LP, ("Facility"), the undersigned and his/her heirs, successors and/or assigns do hereby covenant and agree to assume all risks of, and be solely responsible for, any injury or loss sustained by the undersigned while participating in the Program operated by Salt Lake City Corporation, a municipal corporation of the State of Utah, by and through the Salt Lake City Fire Department ("City") at Facility unless such injury or loss arises solely out Facility's negligence or willful misconduct. Nothing in this Statement of Responsibility shall be deemed as a waiver of any of Participant's rights under the Utah Worker's Compensation Act or Utah Occupational Disease Act as an employee of Salt Lake City Corporation.
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EXHIBIT B

CONFIDENTIALITY STATEMENT
The undersigned hereby acknowledges his/her responsibility under applicable federal and state law and the Agreement between Salt Lake City Corporation, a municipal corporation of the State of Utah, by and through the Salt Lake City Fire Department ("City") and Salt Lake Regional Medical Center, LP, ("Facility"), to keep confidential any information regarding Facility patients as well as all confidential information of Facililty. The undersigned agrees under penalty of law, not to reveal to any person or persons, except to authorized clinical staff and associated personnel for purposes of treatment, payment or health operations of Facility, any identifying information regarding any patient and further agrees not to reveal to any third party any confidential information of Facility, except as required by law or as authorized by Facility.
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Please review the presenation before filling out the test below:

Click here =>SLRMC Mini-Orientation Presentation
I attest that I have received, read and understand the material contained within the SLRMC Mini-Orientation Manual. I am personally responsible to know and abide by the information and best practices contained with in the manual.
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I have received training on OSHA Bloodborne Pathogen Standards, PPE, Bloodborne Pathogens and Sharps Safety.
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For additional questions, please contact

Patricia Watkins, RN, Infection Control (801) 350-8127

Stacey Hornsby, RN, Clinical Educator (801) 350-4800
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Holy Cross - SLC Intubation Waiver

EXHIBIT A

EXHIBIT B