As a student/resident, I understand that I may have access to confidential medical orbusiness 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 St. Claire Regional Medical Center who are identified by written policy as having the "need to know" directly or indirectly, either during of after my internship/coop/shadowing/observation/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, St. Claire Regional Medical Center, 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.

Medical Library business hours are 8:00 a.m. to 4:30 p.m. Monday thru Friday. (The library will beclosed on all major holidays.) AHEC student badges are to be worn at all times while in the medical library. All reference books, journals, audiotapes, videotapes, CDs and software must be used in the library unless otherwise designated. Unauthorized removal of these materials from the library constitutes theft. Use of library PCs for Internet access, CD access, or creation of papers, presentations, etc. is a privilege not a right. Computer settings, passwords, and installed programs are neither to be copied nor altered in any way. The computer lab, providing there are no training classes scheduled, will be available to you during normal business hours as well. You are responsible for providing discs in which to save your documents/assignments on. Do not save any documents/assignments on the library PCs as they will be deleted each day. The PCs are networked to the copy/printing machine located in the library. You may copy/print during regular business hours. Copying articles and printing out assignments, presentations and such is also a privilege not a right. Anyone caught copying or printing anything other than class materials will have copying privileges taken away. The copier will be available during normal business hours only. Food and drinks are permitted in the library. Please be careful if you are eating and/or drinking while working on the PCs. We all know what spilled drinks can do to a computer. Please throw all trash away when you are finished. Literature searches and interlibrary loans are available to you. Please see the librarian assistant if you have any questions about these services. The library is to be kept locked before 8:00 a.m., after 4:30 p.m., on weekends and holidays. All authorized personnel are issued an entry code for admittance during this time. Persons without authorization are not to be admitted by students or others. Library materials designated for circulation may be checked out. (See library staff for more information.) Books may be checked out for one week, audio and videotapes for three days. Check-out cards are located in the back of circulating books and other designated materials. The card is to be filled out, signed and given to the Library Assistant. At the end of the check out period books and other materials are to be returned to the library office. All borrowed materials must be returned before the end of a student’s rotation. Books, journals, and other library materials are not to be reshelved by library users. Please leave these materials on the tables or cart and the library staff will reshelve the materials. Violations of this agreement may be reported to the AHEC office and/or appropriate school officials. By providing my digital signature below, I certify that I have read, understood, and agree to abide by all of the 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 St. Claire Regional Medical Center. I further agree to pay the cost of the badge in the event that I should lose or damage it. That cost is $6.00 for replacement if not returned. If I lose my badge and need to reprint it, the 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 medical library door located on the 2nd floor of the hospital. Please make sure these are returned when you leave or we will have to contact your program coordinator.

As an employee, member of the medical staff, or an employee of an agent of St. Claire Regional Medical Center, I have been provided access to the computer systems at St. Claire Regional Medical Center 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 St. Claire Regional Medical Center. I understand that, as a user of St. Claire Regional Medical Center's 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 St. Claire Regional Medical Center constitute grounds for termination of any relationship between myself or my employer and St. Claire Regional Medical Center.  Unauthorization 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 legislation. I agree to the following stipulations regarding my access to St. Claire Regional Medical Center's 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 of my job. 3. The information will not be disclosed, by me, to any person whatsoever, expect 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 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 St. Claire Regional Medical Center's 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 St. Claire Regional Medical Center. I agree to indemnify St. Claire Regional Medical Center fully for any and all damages, including legal fees that St. Claire Regional Medical Center may incur as a result of my intentional breach of this agreement.  I further agree that upon termination of my work with St. Claire Regional Medical Center, for any reason, I will immediately return any documents containing any confidential information to St. Claire Regional Medical Center and, upon request, that i will certify in writing that all such documents and toher media has been returned to St. Claire Regional Medical Center irreparable harm, for which monetary compensation may not be an adequate remedy, and i agree that St. Claire Regional Medical Center 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 St. Claire Regional Medical Center, 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 St. Claire Regional Medical Center 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 St. Claire Regional Medical Center immediately without cause. I have provided the Northeast KY AHEC and St. Claire Regional 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 St. Claire Regional Medical Center:

• A letter from the institution stating that the student/resident is in good standing
  • Letter must be addressed to Jessica Caudill, 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.)

If your instituiton does not provide the NE KY AHEC with this information, you must submit your documentation below.

All students must submit the following documentation separately.  This documentation is not included in the Letter of Good Standing.