Intake Form

Please complete the survey below to request a nursing shadow experience at The University of Kansas Health System.

Shadow experiences are available:
- Monday-Saturday in the acute (in-patient) setting
- Monday-Friday in the ambulatory (clinic) setting

Requests submitted outside of these parameters wll be declined and you wll be asked to submit a new request.

Requests are reviewed Monday-Friday between the hours of 8:00 AM and 4:00 PM with the exclusion of the holidays listed below. Approval decisions will be made 24-48 hours following request submission.

New Year's Day: Wednesday, 1/1/2025
Martin LutherKing Jr. Day: 1/20/2025
Memorial Day: Monday, 5/26/2025
Independence Day: Friday, 7/4/2025
Labor Day: Monday, 9/1/2025
Thanksgiving Day: Thursday, 11/27/2025
Day After Thanksgiving: Friday, 11/28/2025
Christmas Day: Wednesday, 12/25/2025

If your request is approved you will recieve a confirmation email with instructions on next steps.

If your request is denied you will recieve an email with next steps for scheduling a nursing shadow experience at The University of Kansas Health System.

Thank you!

Date request submitted

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M-D-Y

Is this shadow request related to a scheduled interview?

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Yes

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Please reach out to your talent acquisition partner to schedule a post interview shadow experience.

Is this shadow a requirement for your schooling (i.e. do you need shadow hours for course credit)?

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Yes

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Please reach out to tfletcher@kumc.edu to arrange this shadow experience.

Do you need to complete more than 8 hours of shadowing experience?

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Yes

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What date are you requesting to shadow?

Shadows are available:
- Monday-Saturday in the acute setting
- Monday-Friday in the ambulatory setting
Shadows will last 4-8 hours one day
You will be taken to another form to select your location and time

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M-D-Y

Requests must be submitted at least 7 days in advance. Please choose another date.

Please re-enter your selected shadow date from this list, you can type in the date to narrow the list down

do not select a different date than the one identified above
- if you don't see your date on this list please choose a different date above and try again
- if you need to choose a different date please change the date above first
if the dates do not match or are less than 7 days from today your shadow request is subject to denial

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Date of birth (MM-DD-YYYY)

if you are under the age of 18 you will need a parent or guardian's signature to participate in a nursing shadow experience
Shadow participants must be at least 16 years old

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M-D-Y

Age

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We apologize but shadow participants must be at least 16 years old. Please reapply for a shadow experience following your 16th birthday.

First name

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Last name

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Email address

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Phone number

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Emergency contact name

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Emergency contact phone number

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Emergency contact relation to you (i.e. parent, guardian, significant other, etc.)

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Are you currently enrolled in nursing school?

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Yes

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What school are you enrolled in?

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What will you graduate with?

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ADN

BSN

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What is your expected graduation date?

approximate planned date is acceptable

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M-D-Y

Patients at The University of Kansas Health System (TUKHS) are entitled to confidentiality with regard to their medical and personal information. The right to confidentiality of medical information is protected by state law and federal privacy regulations known as the Health Insurance Portability and Accountability Act ("HIPAA"). Those regulations specify substantial penalties for breach of patient confidentiality.

1. All patient medical and personal information is confidential information regardless of the educational or clinical setting(s) and must be held in strict confidence. This confidential information must not become casual conversation anywhere in or out of a hospital, clinic or any other venue. Information may only be shared with health care providers, supervising faculty, hospital or clinic employees, and students involved in the care or services to the patient or involved in approved research projects that have a valid need to know the information.

2. Under strict circumstances, upon receipt of a properly executed medical authorization by the patient or a HIPAA-compliant subpoena, medical information may be released to the requesting party. Inquiries regarding the appropriateness of the authorization or subpoena should be directed to the medical records department or the University's Office of Legal Counsel at 913-588-7281, depending upon the situation.

3. Computer user codes/passwords are confidential. Only the individual to whom the code/password is issued should know the code. No one may attempt to obtain access through the computer system to information to which he/she is not authorized to view or receive.

4. If a violation of this policy occurs or is suspected, immediately report this information to your supervising faculty or sponsor.

5. Violations of this policy will result in disciplinary action up to and including termination from the program. Intentional misuse of protected health information could also subject an individual to civil and criminal penalties.

I, ______ ______ have read this Agreement and agree to abide by its terms and requirements throughout my educational experience at The University of Kansas Health System and as part of my participation in patient care activities.

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Add signature

Signature date

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M-D-Y

I acknowledge that I have health insurance coverage

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Yes

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Event: Nursing Shadow Experience (the "Event")
Description: The event is a one-day nursing shadow experience within The University of Kansas Health system
Date: ______

IN CONSIDERATION FOR THE OPPORTUNITY TO PARTICIPATE IN THE ABOVE-REFERENCED EVENT, I FREELY AGREE TO THE FOLLOWING for myself and on behalf of my spouse, children, heirs, parents, guardians, next of kin, legal and personal representatives, executors, administrators, successors, and assigns (collectively, "I" or "my"):

1. I warrant that: (a) I am at least 18 years old or I have the permission of a parent or guardian, and (b) I am not under the influence of alcohol or drugs that would in any way impair my ability to participate in the Event.

2. I willingly, expressly, and unconditionally assume all risks and dangers associated with my participation in the Event, whether known or unknown, seen or unforeseen, directly related to the Event, incidental to it, or associated with it. I fully realize and accept that as a result of my participation in the Event, I may sustain severe and permanent physical or mental injury or death, property damage, financial loss, or other injuries. I understand and accept that the physical risks of participation in the Event include, but are not limited to, strains, sprains, fractures, lacerations, contusions, traumatic brain injuries, or permanent physical disability arising out of serious neck or back injuries.

3. I understand and acknowledge that UKHA does not carry general liability insurance or medical insurance on my behalf. In the event that I am injured at any time during my participation in the Event, I agree to accept full responsibility for and to pay the cost of medical care, transportation, and other incidental expenses.

4. I hereby release, waive any claims against, and agree to hold harmless and to indemnify the University of Kansas Hospital Authority with respect to any liability, claims, demands, causes of action, damages, losses, or expenses (including court costs and attorneys' fees) of any kind or nature arising out of, or in connection with, my participation in the Event or this agreement.

5. I hereby accept responsibility for my own conduct and actions while participating in the Event.

I HAVE READ THIS AGREEMENT, AND I UNDERSTAND AND AGREE TO ALL OF ITS CONTENTS.

Participant name: ______ ______

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Add signature

Signature Date

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M-D-Y

Since The University of Kansas Health System has agreed to allow me to be on its premises for an experience, I, ______ ______
agree/understand that:

1. I will complete required TUKHS HIPAA training, regarding patient confidentiality obligations, before being allowed to participate in the experience.

2. I will abide by the TUKHS policies and procedures, including HIPAA, and will conduct myself in a professional manner at all times.

3. The experience may involve risks of injuries or health exposures and I agree that participation in the experience and risks are being voluntarily assumed.

4. The State of Kansas, the Kansas Board of Regents, the University of Kansas, the University of Kansas Medical Center, The University of Kansas Hospital Authority, University of Kansas Physicians, KU HealthPartners, Inc., any corporations or entities affiliated with the foregoing, and all employees, officers, agents, representatives, and volunteers of the foregoing (together, the "Released Parties") are hereby released from any and all liability related, directly or indirectly, to the shadowing experience and that I agree to hold the Released Parties harmless from any and all liability, causes of action, or other claims related to the student's participation in the experience.

I ______ ______ agree to assume all risks and be solely responsible for any injury, loss, or damaged sustained while involved in the experience.

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Add signature

Signature date

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M-D-Y

I acknowledge that any medical treatment will be my financial responsibility and not that of the University of Kansas Health System.

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Add signature

Signature date

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M-D-Y

I, the undersigned, state that I am the parent/legal guardian of ______ ______. I understand that the above terms and conditions apply to ______ ______ and to myself. I further understand that ______ ______ cannot participate under ANY circumstances in the above specified event or program without parental consent and that ______ ______ will not be allowed to participate without entering into this agreement. This document is binding upon myself, ______ ______, and any person suing on behalf of ______ ______.

Emergency Contact

I authorize The University of Kansas Health System to provide routine first aid in the case of illness or injury. If a parent/guardian cannot be reached, I give my permission for The University of Kansas Health System to authorize emergency treatment for ______ ______ at The University of Kansas Health System. I acknowledge that any medical treatment will be my financial responsibility and not that of The University of Kansas Health System.

Emergency Treatment Authorization

In exchange for allowing ______ ______ to participate in this event or program, ______ ______ by and through the undersigned, agrees to release from liability, indemnify, and hold The University of Kansas Health System, its trustees, employees, agents, volunteers, and/or assigns from any and all claims, demands, losses, expenses, actions or causes of action to the minor's person or damage to ______ ______'s property which arises out of or occurs during or as a consequence of ______ ______'s participation in the event or program, whether or not such injury or damage may have been caused, in whole or in part, by any negligence or want or care on the part of The University of Kansas Health System, its trustees, employees, agents, volunteers and/or assigns

Parent or legal guardian's printed name

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Parent or legal guardian's signature

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Add signature

Signature date

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M-D-Y

Acknowledgement

I, the undersigned, state that I am the parent/legal guardian of ______ ______. I understand
that the above terms and conditions apply to ______ ______ and to myself. I further understand that ______ ______ cannot participate under ANY circumstances in the above specified event or program without
parental consent and that ______ ______ will not be allowed to participate without entering into this agreement. This document is binding upon myself, ______ ______, and any person suing on behalf of ______ ______
Name: ______
Signature:

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Add signature

Signature date

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M-D-Y

It is possible to acquire infections such as HIV, Hepatitis B and Hepatitis C through contact with blood and body fluids. While measures are in place to provide a safe hospital environment, you should always be on the alert for items such as contaminated needles or dressings. If you see a potentially contaminated item, notify a healthcare worker so it can be disposed of properly. Do not handle it yourself.

Hand hygiene is the most important way to prevent the spread of germs. Wash your hands promptly and thoroughly when they are soiled, between patient contacts, after touching potentially contaminated surfaces, after using the restroom, and before eating. When your hands are visibly clean, alcohol-based hand rub is an effective alternative to soap and water.

Patients may be placed in isolation for a variety of reasons. Depending on the type of isolation, there are protective measures the healthcare worker must take. For the patient's and your safety please do NOT enter these rooms with the caregiver.

It is important to protect patients from infections. Please do not participate in your educational activities if you have an infectious disease that could be spread to others (i.e., fever, purulent drainage, unexplained rash, productive cough, etc.).

Thank you for following these instructions. Please contact the Hospital's Infection Control Department @ 913-588-2779 with any questions.

Applicant's name: ______ ______

I have read and agree to comply with the practices described above

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Add signature

Applicant's parent/legal guardian name

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Applicant's parent/legal guardian signature

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Add signature

Signature date

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M-D-Y

Because I may have patient contact during my educational experience, I can attest that I have the following current immunizations:

Tetanus-Diphtheria
Hepatitis B
and Influenza (if shadowing October through April)

UPDATE: as of August 7, 2023 the health system no longer requires the COVID vaccine.

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Add signature

Signature date

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M-D-Y

You must review the Privacy and Confidentiality (HIPAA) Training material below and pass the associated quiz before you can submit your application.

Click "Being the quiz" to take the Privacy and Confidentiality Training Quiz

(Once all nine (9) questions are answered correctly you will see a question to acknowledge the quiz is complete.)

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Begin the quiz

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Privacy and Confidentiality Training

Attachment:The University of Kansas Health System HIPAA.pdf

1. What is the purpose of HIPAA?

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Maintain insurance coverage during job changes

Protect privacy and security of health information

Establish new health care billing standards

All of the above

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2. Protected health information includes

Past, present, or future health

Identifies and individual,either directly or indirectly

Can be electronic, paper, or oral

Includes information that is exchanged in conversation, by fax, or by email

All of the above

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3. The Privacy Rule only applies to health care workers at The University of Kansas Health System.

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True

False

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4. You run into a family friend while you are walking around the hospital, you get to talking and find out
that they have been diagnosed with cancer and will be getting treatments here. They disclose that your
family knows, and to tell them that they say hi. When you go home you tell your family that you
saw their friend at the hospital today and they say hello. Did you violate HIPPA?

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Yes

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5. You walk by a waiting room and notice your neighbor sitting there. You should...

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Call the neighbor and ask why they were at the doctor's office

Tell your family that you saw them

Keep the information to yourself

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6. If a friend says, "I heard Mary Jones is in the KU Hospital. Did you see her there?" You should respond:

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Yes,I did see her today when I was shadowing Dr. Johnson

I have no information about that

No, I didn't see her but let me see if I can get some information

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7. Your mom knows you are involved in a shadow experience activity at the University of Kansas Health System. She calls to ask if you can get the room number of a friend, who she believes has been admitted to the KU Hospital. You:

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Ask someone in the department you are shadowing to look up the information in O2 and provide the room number to your mom

Refer her to the hospital operator

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8. During your educational experience at the University of Kansas Health System you observe a trauma victim who came in through the Emergency Department. You find the case very interesting, so you log into Facebook and update your friends about the situation. Is this appropriate?

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Yes, my account is set to a private setting so only my friends could see the posting.

No, this is a potential HIPAA privacy violation

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9. Posting digital images or messages containing protected health information on social media platforms is fine since the information is not "searchable."

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True

False

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This answer is not correct. Please try again.

Once the quiz question is answered correctly, you will no longer see this message and can proceed to the next question.

Congratulations, you have completed the Privacy and Confidentiality Training Quiz requirement!

Please acknowledge that you agree to abide by HIPAA law and understand this requirement is complete.

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I acknowledge I have completed the Privacy and Confidentiality Training Quiz and agree to abide by HIPAA law.

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Thank you for submitting your request. A member of the nursing recruitment and retention team will be reaching out to you to arrange your shadow experience. Please select submit below.

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.