LVHN Student Observation Application

The term “LVHN” means Lehigh Valley Health Network part of Jefferson Health and its directors, officers, employees, subsidiary organizations, affiliates, and agents acting within the scope of their duties.

 I hereby freely, voluntarily, and without duress, execute this consent form (“Consent Form”) under the following terms and conditions:

1. Age of Participant. I certify that Participant is at least fourteen (14) years of age.

a. For Participants Age 18 or Older. If I am the Participant executing this form on my own behalf, I certify that I am at least eighteen (18) years of age.

2. Emergency Information. I hereby permit and authorize LVHN for a period of one (1) year from the date on the signature page of this Consent Form to perform any and all treatment including, but not limited to medical, dental, and surgical, that may be necessary in the event of an emergency concerning Participant. The following information is being requested in order to be able to react appropriately in the event of an emergency. Please provide any information which might be relevant (e.g., medical conditions and allergies) in case of an emergency on the attached Exhibit A.

3. Program Activities. During the Program, Participant will hear from different presenters having subject matter expertise and may participate in hands-on activities. The Program does not include any interaction between Participant and patients, but does it include observation of health care services being provided to patients.

5. Assumption of Risk and Release. I understand that the Program is focused on health professions education, and that while participating in the Program, Participant may come in contact with, be around, and/or be exposed to medical devices/equipment (e.g., needles, sharps, surgical instruments), biohazards, latex, diseases, and other risks typical of a medical facility. I also understand that the Program may involve mental and physical exertion. I understand and acknowledge that such risks may result in illness, personal or psychological injury, pain, suffering, temporary or permanent disability, death, property damage, and/or financial loss to Participant. I authorize Participant to participate in the Program knowing that such participation involves risks including, but not limited to, those listed herein, and I hereby assume all risk associated with the Program. I, on behalf of Participant, and my/our respective heirs, assigns, executors, and personal representatives, hereby release and forever discharge LVHN from any liability or claim that I/Participant, may have against it with respect to any bodily injury, personal injury, illness, death, property loss or property damage that may result from Participant’s participation in the Program. I further agree to indemnify, defend, save and hold harmless LVHN from any and all claims for injuries or damages arising from or related to Participant’s participation in the Program.

6. Acknowledgement of Personal Liability; Immunizations. I understand that I remain legally responsible for any personal actions taken by Participant. I certify that Participant has complied with the Pennsylvania School Immunization Requirements and understand that if Participant is exempt from immunizations, Participant may not participate in the Program.

7. Conduct. I am aware that Participant is attending a program at an LVHN site. I understand that Participant’s participation in the Program is for educational purposes, and that there is an expectation that Participant will be courteous and respectful to LVHN staff educators, patients, visitors of LVHN, employees, and fellow participants. I understand that in the event any issues arise, Participant may be immediately removed from the Program at the sole discretion of LVHN. If Participant is removed from the Program, I will be responsible for ensuring Participant is picked up from the LVHN site within a reasonable time. LVHN reserves the right to request that Participant not participate in future events if Participant has displayed disruptive behavior during the Program.

8. Prohibited Activities. I understand that Participant is prohibited from having weapons anywhere on campus, including in locked personal vehicles. I understand that the consumption or use of tobacco, drugs, or alcohol products at an LVHN site is strictly prohibited and that Participant will not to consume, use, possess, or be under the influence of any tobacco, drugs, or alcohol products while at an LVHN site. Participant will not enter unauthorized areas.

9. Confidential Information. I understand that, in the course of the Program, Participant may have incidental exposure to certain data and information that is considered confidential, including, but not limited to, information about LVHN’s activities, patients, personnel, students, and/or business practices. I understand that any and all data and information that Participant may receive or otherwise discover while participating is considered “Confidential Information.” Participant will not disclose or discuss any Confidential Information with any third parties while participating in the Program or at any time after the Program is completed.

10. HIPAA. I understand that LVHN is “covered entity” as defined under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and that Participant may have incidental exposure to “protected health information” as that term is defined under 45 CFR § 160.103 in the course of the Program. Participant will keep all such information confidential.

11. Cell Phones, Pictures, and Videos. I understand that Participant may not take pictures, videos, or recordings while participating in the Program, including through the use of any personal electronic devices (e.g., iPhone or Android devices, etc.).

I understand that as an employee of Lehigh Valley Health Network, or an affiliate, related entity, or subsidiary thereof (Lehigh Valley Health Network, along with its affiliates, related entities, and subsidiaries are hereinafter referred to as “LVHN”), or as member of the LVHN medical staff, Allied Health Professional, or as a non-employed patient care provider or support personnel (volunteer, intern, student, contractor, vendor, etc.), the performance of my job may require me to access or become aware of Confidential Information and/or trade secrets of LVHN. I agree that for purposes of this Acknowledgement and Agreement (hereinafter the “Acknowledgment”), the term “Confidential Information” shall include, but shall not be limited to the following: patient information; information regarding advertising; methods; know-how; techniques; referring entity information; business information; provider performance information; systems; processes; software programs; technical information; works of authorship; financial information; business plans; projects; plans; proposals; rate schedules; rate quotations; the identity of suppliers; correlated data related pertaining to the care or treatment of patients or provider performance; or any other Confidential Information or trade secrets of LVHN which would otherwise come into my knowledge during the term of my employment with LVHN.

I understand that access to and use of this information in verbal, written, or electronic form is a privilege. I also understand that access to information is granted to me based on business or clinical “need to know” standards and the responsibilities of my job as an employee or nonemployed patient care provider or support personnel.

I understand that I may not seek Confidential Information that is not required to do my job. I also understand that I may share Confidential Information only when necessary to do my job. I agree to store and dispose of Confidential Information which I use in a way that ensures continued security and confidentiality. I agree that I will not make unauthorized copies, screenshots, or otherwise duplicate any Confidential Information. In this regard, I agree that I will not at any time, whether during or after the termination of my employment (or the termination of my non-employed status as a patient care provider or support personnel), for any reason, reveal to any person or entity any of the trade secrets or Confidential Information of LVHN or of any third party which LVHN is under an obligation to keep confidential except as may be required in the ordinary course of performing my duties for LVHN. In addition, I am permitted to access my own non-sensitive health information or information pertaining to an immediate family member provided I follow the procedures set forth under the Administrative Policies entitled “HIPAA – Release of Protected Health Information” and “HIPAA – Confidentiality”.

I agree that upon either termination of my employment or engagement with LVHN for any reason, or at such time as LVHN may so request from time to time, I shall immediately return and redeliver to LVHN all property of LVHN including, but not limited to, the following: (i) any and all written information, material or equipment that constitutes, contains or relates in any way to LHVN’s Confidential Information and any other documents (whether in hard copy, electronically stored or in any other medium or form, now or hereafter in existence); and (ii) all tangible material embodying any element of such Confidential Information, constitutes, contains or relates in any way to LVHN’s Confidential Information and all notes, summaries, memoranda, drawings, manuals, records, excerpts or derivative information deriving from above (i) and/or (ii), and all other documents or materials (“Notes”) (and all copies of any of the foregoing, including “copies” that have been converted to computerized media in the form of image, data or word processing files either manually or by image capture) based on or including any Confidential Information, in whatever form of storage or retrieval. I shall not knowingly maintain Confidential Information or copies or Notes thereof after termination of this Agreement or that is unrelated to the performance of my duties. 

I understand that the methods I use to get Confidential Information may only be used in the performance of my job. If I require special authorization to access computer-based information, I understand that my computer or system sign-on information may only be used by me. I also understand that I may not give my computer or system sign-on information to anyone, and that this sign-on information is the same as my written signature. I accept full responsibility for any use of my computer or system sign-on information.

I understand that Lehigh Valley Health Network has a Corporate Compliance Program and I acknowledge that I have been provided education regarding the program. I also understand that I have a role in preserving Lehigh Valley Health Network’s integrity and thus have an obligation to report potential compliance issues. I am aware that the Compliance Hotline number, 1-877- 895-2905 and that I can report compliance issues by filling out a form on the internet at www.LVHN.ethicspoint.com.

I declare that I have read and understand this Acknowledgement and am legally bound by the requirements set forth herein. I have had an opportunity to ask questions and have them answered. I recognize that disclosing Confidential Information at any time during or after my employment or engagement with Lehigh Valley Health Network may cause irreparable damage to Lehigh Valley Health Network, its patients or health care providers. I agree that if I violate any term of this Acknowledgement, I may be subjected to disciplinary action, up to and including termination of my employment. Additionally, LVHN or the owner of such information may seek any and legal remedies against me, including seeking injunctive relief, in addition to any other existing rights provided in this Acknowledgement or by operation of law, without the requirement of posting bond. Additionally, in the event that I breach any of the provisions of this Acknowledgement, LVHN shall be entitled to an award of reasonable attorneys’ fees and costs incurred by it as a result of my breach. The remedies provided in this Acknowledgement shall be in addition to any legal or equitable remedies existing at law and shall not be construed as a limitation upon, or an alternative for, or in lieu of, any such remedies. If any provision of this Acknowledgment or application thereof to anyone or under any circumstances is adjudicated to be invalid or unenforceable in any jurisdiction, such invalidity or unenforceability shall not affect any other provisions or applications of this Acknowledgement that can be given effect without the invalid or unenforceable provisions or applications and shall not invalidate or render unenforceable such provision in any other jurisdiction or under any other circumstance.

This Acknowledgment shall be governed by the laws of the Commonwealth of Pennsylvania. The parties recognize and accept that the Court of Common Pleas of Lehigh County, Pennsylvania shall have exclusive jurisdiction and venue for any disputes under this Acknowledgment. I understand that nothing in this Acknowledgement changes the at-will status of my employment with LVHN (if an LVHN employee) or gives, or shall be deemed to give, me any right to continued employment for any length of time.

LEHIGH VALLEY HEALTH NETWORK
PART OF JEFFERSON HEALTH

MEDIA CONSENT FORM (PARENTAL)

 THIS IS A SEPARATE CONSENT

Consent for Media Participation at Lehigh Valley Health Network part of Jefferson Health

I am providing consent to the taking and public use of any photographic, audio visual or other media recordings or written articles of the me/my child related to my/my child’s participation in the Program. I consent to the use of my/my child’s name, voice, and/or image in any Lehigh Valley Health Network related publication or project.  I waive any right that I may have to copyright, inspect, or approve the finished project that may be used hereunder, or the specific use or context to which it may be applied. I release Lehigh Valley Health Network, its subsidiary organizations, employees, and agents from any liability connected with the taking or use of these audio or visual recordings or representations. I understand that this consent is provided voluntarily and that it is not necessary to sign this form as a condition of my/my child's participation in the Program. I understand that I will not receive compensation in connection with the use of my/my child’s name, voice, and/or image.

If authorization is granted, Lehigh Valley Health Network can rely on it until it is revoked or until it expires. The revocation must be in writing. The revocation will be effective immediately upon receipt of written notice of revocation; however, it will not prohibit us from any disclosures we have made or acts we have already taken in reliance on this authorization.  The authorization is in effect for two (2) years from the date of signing. Upon conclusion of that time period, this authorization is automatically revoked and no further use of the information is permitted beyond that date.