The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

2SAU6Ms76wrVb9reakSoAcbb4fsf6UdwmuozP3KVRcWSAbwGdKyGjH5R6G8Bcn42T2U7aQCMNen5XUj8fypjFXMT83IVIZ

Intake Survey for Visiting Medical Student Shadows

Thank you for your interest in a learning experience at TUKHS. Please complete the survey below as part of your orientation. It should take about 10-15 minutes. NOTE: You will be asked to upload proof of immunizations/vaccinations as part of the intake process.

Thank you!

First and last name

* must provide value

Credentials

* must provide value

Email address

* must provide value

Cell Phone Number

* must provide value

Emergency contact information

* must provide value

Current School Attending

* must provide value

TUKHS Sponsor of clinical experience: Name and Department

* must provide value

Start date of clinical experience

* must provide value

M-D-Y

End date of clinical experience

* must provide value

M-D-Y

Privacy and Confidentiality Agreement

Patients at The University of Kansas Health System 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. 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.

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

4. 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.

The Covid-19 Reintegration Guide provides pertinent information for all visitors regarding processes during this pandemic. Please review.

Attachment:Covid Student Reintegration Guide_Updated 2.24.22.pdf

Because I will be in a patient care setting, I am attaching proof of the following current immunizations:
Td or Tdap
MMR
Hep B
Varicella
Influenza (if shadowing October through April)
Covid-19 vaccine or exemption approval.

Please upload proof of the above.

* must provide value

Upload file

I, ______ have read this Privacy and Confidentiality Agreement and agree to abide by its terms and requirements throughout my educational experience at The University of Kansas Health System.

I understand this is a shadowing opportunity, and I will not provide any patient care or physical or verbal contact with patients during my time in the organization.

Providing any patient contact would require full credentialing.

* must provide value

Add signature

Signature Date:

* must provide value

M-D-Y

As part of your orientation, you must review the
attached Privacy and Confidentiality presentation
and correctly answer the quiz that follows.
Click "Yes" to take the Privacy and Confidentiality
Training Quiz
(Answer the 10 questions, once all are correct you
will see a question to acknowledge the quiz is
complete.)

* must provide value

Yes

reset

HIPAA and Confidentiality Presentation: Open and Review

Attachment:HIPAA Training.pdf

What is the purpose of HIPAA?

* must provide value

Maintain insurance coverage during job changes

Protect privacy and security of health information

Establish new health care billing standards

All of the above

reset

Protected health information includes:

* must provide value

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

reset

The Privacy Rule only applies to health care workers at The University of Kansas Hospital.

* must provide value

True

False

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In the event I violate the HIPAA Rules

* must provide value

Only the health system can be fined

I can be sent to prison for up to 10 years

I can personally be sued by the person whose PHI I violated

I can be sent to prison for up to 10 years and be sued by the person whose PHI I violated

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

* must provide value

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

* must provide value

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

reset

Your mom knows you are involved in an educational experience activity at the KU Medical Center. She calls to ask if you can get the room number of a
friend, who she believes has been admitted to the hospital. You:

* must provide value

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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During your educational experience 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?

* must provide value

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

reset

Known or suspected incidents involving use or disclosure Patient Health Information or Personal Information through social networking are reported to the appropriate KUMC privacy office and are investigated.

* must provide value

True

False

reset

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

* must provide value

True

False

reset

Congratulations, you have completed the Privacy and
Confidentiality Training Quiz requirement!
Please acknowledge that you understand this
requirement is complete.

* must provide value

I acknowledge I have completed the Privacy and Confidentiality Training and Quiz.

reset

You answered this questions incorrectly. Try again...

You will receive an email confirming you have completed this orientation requirement.

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.