Item Date completed Notes

Between October 1st & March 31st

Series of 3 vaccines or if no vaccine record, need titer

Must be within past 10 years

Series of 2 vaccines or if no vaccine record, need titer

Series of 2 vaccines or if no vaccine record, need titer

Date manager approval of rotation dates obtained: Name of manager:

Current contract and Certificate of Liability must be on file at HCMH-manager may verify with aatkinson@hughchatham.org.

Instructor Signature: ____________________________________________________________________ Date: _______________________

Attention Instructor : Complete and submit to clinicalsite@hughchatham.org. By Signing this form you attest that the all

student requirements are met and student is clear for clinical.

Influenza Vaccine (Flu Shot) Expiration:

Chicken Pox (Varicella) Completion:

Confidentiality Agreement Signed:

Hepatitis B Series Completion:

Tetanus Diphtheria Pertussis (Tdap) completion:

Mumps Measles Rubella (MMR) Completion:

Identification Badge Obtained:

Criminal Background Check Completion:

Drug Screen Completion:

Basic Life Support (BLS) Expiration:

Immunization

Record may be

used as proof.

Full Student Passport180 Parkwood Drive

Elkin NC 28621

For Questions Contact Department Manager (see process flow map)

2 Step TB Skin Test (PPD) Expiration:

Requirements

School Contact Name:

Instructor must contact Manager/Director of unit for approval of clinical.

School Affiliation:

School Address:

School Contact Phone:

Student Name:

Student Address:

Student Phone:

Alternate Phone:

Student EMAIL:

* Please note: BLS is not required for High School Students*

Rotation End Date:

Star's Acknowledgement Form Signed:

If no PPD within previous 2 years, must have 2 step PPD (at least 1 week

apart).

HCMH Safety/Environment of Care Checklist:

Completed within 30 days of first date of clinical experience at HCMH,

current as long as student stays enrolled in program and is active with Hugh

Chatham. *Please note: Drug Screens and Criminal Background Checks are

not required for students under the age of 18.*

Essential Policy Review:

Includes education on the following:

Hand Hygiene/Blood-Borne Pathogens, Infection

Prevention/Exposure Control Plan Education, Standard

Precautions/ Fingernail Policy, Right to Know Law/

Hazardous Material, Back Safety, HIPPA/

Confidentiality.

Rotation Start Date:

Clear Sanction Check

(http://exclusions.oig.hhs.gov/)

Compliance Form Signed:

Student/school establishes contract through Amanda Atkinson and/or

Administration.

Student works with instructor to meet all elements required on passport from

PCP or local clinic.

HR sets up student in Evident and forwards info to MIS, school and manager. Manager sends security access form to MIS if applicable.

Final schedule for students sent to clinicalsite@hughchatham.org and

manager by school.

Instructor emails only completedgroup or individual passports 2 weeks

prior to start date to clinicalsite@hughchatham.org.

*School maintains all copies of tests and health records.

Clinical Managers/Directors:

PROCESS FOR MANAGING STUDENT CLINICAL ROTATIONS AT HCMH

Items to remember:1. Contact manager of area first for approval of clinical site.2. Email passports when complete to clinicalsite@hughchatham.org.

3. Instruct company to email pertinent Criminal Background Checks (CBCs) to HumanResources@hughchatham.org.

PRIORITY STEP:Instructor contacts manager of unit

(see contact list) for approval of clinicalsite prior to proceeding.

Instructor mandates that any pertinent CBC records be sent directly

to HR* for review.

Student Type Access Mgr Phone # Email

Nurse Med Surg Evident Rodney Buff 527-7434 rbuff@hughchatham.org

CNA Med Surg Evident Rodney Buff 527-7434 rbuff@hughchatham.org

ED-EMT, NP, PA,RN None Lynn Kennedy 527-7409 lkennedy@hughchatham.org

Phlebotomy None Ricky Sawyers 527-7316 rsawyers@hughchatham.org

Med Tech None Ricky Sawyers 527-7317 rsawyers@hughchatham.org

Radiology None Missy Church 527-7398 mchurch@hughchatham.org

Respiratory None Wendy Triplett 527-7427 wtriplett@hughchatham.org

PT/OT Evident Becky Dumas 527-7420 bdumas@hughchatham.org

Pharmacy Evident, CL Gregg Holcomb 527-7220 gholcomb@hughchatham.org

PA/NP Offices/hospitalist none April Maines 527-3389 amaines@hughchatham.org

Dietician Evident Warren Bates 527-7419 wbates@hughchatham.org

OR none Doug Underwood 527-7415 dunderwood@hughchatham.org

Rad Oncology none Suzette East 527-7574 seast@hughchatham.org

OB Evident Gail Poplin 527-7401 gpoplin@hughcatham.org

Medical Records None Theresa Minter 527-7307 tminter@hughchatham.org

Others-Ask operator for manager of specific area 527-7000

1

Clinical Student Information

• OSHA is the agency that requires employers to have written emergency and fire protection plans.

• Everyone is responsible for safety and emergency preparedness in the workplace.

• Housekeeping is very important to our facility because they keep exits clear and maintain the accessibility to fire response equipment.

What Every Employee Should

Know….• What does R.A.C.E. stand for?

• R = RESCUE anyone in immediate danger.

• A = ACTIVATE ALARM. Code 505 or wall pull stations

• C = CONTAIN fire by shutting off oxygen source and closing doors.

• E = EXTINGUISH fire if possible, prepare to evacuate if necessary.

Alarms• “Code RED and the location of

the fire” will be announced over the hospital PA system.

• Main alarm system will sound.

• All elevators will return to the first floor and all fire doors will automatically shut.

• All employees are to follow the established policy that will be discussed in your departmental orientation. -- R.A.C.E.

• Fire suppression system will automatically signal an alarm to the fire department.

Fire Response

• Notify Respiratory Therapy if it will be necessary to shut off Oxygen valves. They are responsible for overseeing the shut off of Oxygen. Before it is turned off, they must be notified.

How do you operate a Fire Extinguisher?

To Use:

1. Hold the extinguisher upright and PULL ring on the handle.

2. Stand back approximately 10 feet, AIM at the base of the fire.

3. SQUEEZE the lever.

4. SWEEP from side to side until the fire is extinguished.

P.A.S.S.

Extinguisher Use

EXTINGUISHER TYPES

Extinguishing Equipment

�A - For combustibles such as trash,

wood, or paper

�B - For flammable liquids or gases

�C - For electrical fires

�D - For combustible metals like

magnesium

Another suppression device is the

sprinkler system.

2

Dangers

• Heat

• Flames

• Smoke

• Toxic Vapors

• Explosions

• Suffocation

WHAT ALL EMPLOYEES

SHOULD KNOW…..• Code Triage is the code for disaster.

• Plan I – Minor, can be handled with available personnel and ones on call.

• Plan II – Major- An event which impacts the hospital necessitating calling in additional personnel.

• Plan III – Major –Evacuation of hospital or nursing center to PT Department or National Guard Armory.

What Every Employee Should

Know….• Line of Authority:

• Incident Commander

• Hospital Administrator

• Chairman of Safety Committee

• Chief of Staff

• Chief Nursing Officer

• ER Medical Director

Disaster Assignments

• Notification: Existing lines of authority will instruct operator to overhead page “CodeTriage” three times and announce Plan II or Plan III. Plan I will not be announced through paging system.

• ALL DEPARTMENTS HAVE SPECIFIC ASSIGNMENTS. Please ask your department manager during department specific orientation of your department’s responsibilities during a disaster.

WHAT EVERY EMPLOYEE SHOULD

KNOW ABOUT CHEMICAL HYGIENE…

To be safe working with chemicals, you must:

1. Know the chemical your are handling.

2. Know your MSDS system, where they are located and how to use them.

3. Use proper techniques for using, handling, storing and disposing of any HAZARDOUS MATERIALS.

• If a HAZARDOUS MATERIAL is spilled in your department, DIAL 7396and speak with Dan Gillespie, the department head that is in charge of Environmental Services and HAZMAT.

Hazard Chemical that will harm you is a

hazardous Chemical

MSDS-Material Safety Data Sheet

A complete catalogue of all chemicals is located in the ER

Security…What all employees

should know• CODE GREY is

security assistance

• When “Assistance Please Location” is called report to that area to assist with restoring order.

• Do not hesitate to call 911 if the situation warrants.

3

Security…What all employees

should know…• CODE PINK– Infant/Pediatric

Abduction

• When a “Code Pink” is paged over the intercom it refers to an infant/pediatric abduction.

• All employees are to observe anyone who appears suspicious and is carrying an item which could be used to conceal a child, (i.e. a bag, suitcase, etc)

Security…What all employees

should know….• CODE Silver– Hostage Situation

• A “Code Silver” is paged when a hostage situation has occurred.

• If an employee encounters a hostage situation, the employee should dial “0” for the switchboard and let the operator know to page a “Code silver ”. The operator will page the code on the overhead speaker and then call the Nursing Supervisor who will then call the police.

• The employee who encountered the hostage situation should try their best to contain it in one area until the police arrive.

OTHER CODES OF

IMPORTANCEOTHER CODES THAT YOU

SHOULD BE AWARE OF ARE:

• CODE BLUE—Cardiac Arrest

• Code Yellow —Bomb

• CODE M– Missing Resident

• CODE E– Elopement

Back Safety

• More back injuries occur at home.

• Poor posture can cause back pain by

disrupting the back’s natural curve.

• Two things to check before attempting a

load are to size up the load and clear the

pathway.

• Always lift with your legs.

Back Safety

• Back injuries can include, strained

muscles, sprained or torn ligaments, bulging disk, herniated or ruptured disc.

• Most back injuries occur because the back is not properly conditioned for strenuous

work.

• Designate a leader when conducting a

team lift.

Back Safety

• Back injuries are usually the result of

years of abuse until the back weakens and snaps.

• Material handling equipment can include patient lifts, carts, forklifts, etc.

• The back has more strength pushing than it does pulling..

4

HIPAA SECURITY TRAINING

GENERAL REQUIREMENTS• Ensure confidentiality, integrity and

availability of all Protected Health Information (PHI)

• Protect against any reasonably anticipated threats or hazards to the security of PHI

• Protect against any reasonably anticipated uses or disclosures of information

• Ensure compliance by the workforce

WHO IS RESPONSIBLE FOR

HIPAA SECURITY?• Every employee is

responsible for

ensuring:

– Confidentiality of Protected Health Information (PHI)

– Protecting against threats or hazards to security of PHI

– Compliance

Conclusion: HIPAA Security is

Your Business.• HIPAA Security is the

LAW and Everyone’s

Responsibility to Enforce.

• Be Responsible

• Be Observant

• Be Compliant

ACCESS CONTROL

Physical and Technical

Safeguards

Physical Safeguards

• Facility Access Controls

– Facility Security—safeguarding equipment

– Access control and validation—Name Badges, Keyed entry, locked file drawers and cabinets

– Access control records

5

Facility Access

• Locking doors to equipment rooms

• Maintenance: repairs to hardware, doors,

locks, etc are documented

• Key distribution and inventory managed by

Plant Operations

• Cabinets and drawers containing PHI will

be locked when not in use

Workstation Use and Security

• Hospital computer equipment is to be used for business purposes only

• Hospital computer equipment will not be removed from the hospital without MIS consent

• Outside computer equipment will not be brought into hospital for use without MIS consent

• Outside computer equipment will not be connected to the hospital network without MIS consent

continued

• Hospital computer equipment will be

screened from public view

• Unattended computers must be logged off

• Computer access will not be sharedPatient Rights

Your right’s, My right’s, Patient Right’s

• Right to care regardless of ability to pay

• Right to participate in care decisions

• Right to file a grievance

• Right to have pain controlled

• Right to make informed decisions

Patient Rights

• Right to formulate advanced

directives

• Right to privacy

• Right to safe setting

• Right to be free of restraints

• Right to be free from all forms

of abuse and harassment

6

Patient Rights

• Right to have family member or representative visit and receive information

• Right to access information contained in clinical records within a reasonable time frame

• Right to confidentiality• Right to use Case Management

Department for aide in finding help outside the hospital

What are Advanced Directives

• A document allowing a person to give directions about future medical care or to designate another person to make medical decisions if the

individual loses decision-making capacity

• Every patient is asked upon admission if he of she has an advanced directive.

Abuse and Neglect

• STATE LAW

• Physicians and other professionals providing services to children and elderly are required by the state to report suspected incidents of child/elder abuse and neglect

STATE LAW

• Reporting Abuse and neglect

– Report to supervisor any signs, symptoms, suspicions, conversations, etc. of possible abuse

– Supervisor to discuss employees concerns with patient’s physician

– Report to County Social Services Department

Ethics Committee

• 1. Principles of right or good conduct

• 2. Rules or standards governing the conduct of the members of a profession

»Anyone who has a question or concern regarding ethics, may refer it to Susan Briscoe, Chief Nursing Officer, who is our hospital liaison for the Ethics Committee

Restraints

• Policy

• Behavioral vs non-behavioral

• MD order, signature

• PRN Order-not acceptable

• Alternatives (minimized use)

• Types restraints

• Annual Staff Competency

• Documentation

• Patient/Family Education

• Notification to family/significant other

• Seclusion is not offered at Hugh Chatham (if needed then patient is transferred)

7

Restraints continued

• Look at how staff behaviors can effect patient behavior.

• Useful techniques for medication, de-escalation,

self-protection, time out.

• How to recognize physical distress in patients who are

being held, restrained or secluded.

Death and Dying

• POA for healthcare needs• Advanced Directive clear• Communication between physician, nurse, and patient,

family, and caregiver• Consideration for organ donation• Emotional, physical, spiritual needs• Pastoral service• Grievance tray/dietary-nourishment needs• Pain control• Comfort measures• Time and space• Sensitivity to patient’s rights, values, religion, cultural

diversity needs and philosophy

Why have a Safety Plan?

• IOM Report-Medication errors are the 8th leading cause of death

• Improve Patient Safety and Reduce Risk

• Create an Environment Focused on Medical/Health Care Error Reduction

• Cost of Medical errors has increased dramatically. Studies showed the cost of adverse events was 37.6 billion/year and preventable events account for 17 billion of that.

IMPROVING YOUR

HAND HYGIENE PRACTICES

Purpose:

To review the importance of good

hand hygiene reducing the risks of

spreading germs by using soap

and water and/or alcohol-based

hand rubs

Hand Hygiene monitoring is

conducted randomly thru-out the

facility

Why is compliance with recommended hand hygiene

so poor?

•heavy workloads

•skin irritation caused by frequent use of soap and water

•hands don’t look dirty

•hand washing with soap & water takes too long

Many personnel don’t realize when they have germs on

their hands

By doing simple tasks, like:

•pulling patients up in bed

•taking a blood pressure or pulse

•touching the patient’s gown or bed sheets

•touching equipment like bedside rails, over-bed tables, IV pumps

8

If your hands are:

•visibly contaminatedwith blood or body fluids

•before eating

•after using the restroom

Hospital acquired infections are most

frequently spread by not washing

hands.

When should you wash your

hands with soap and water?

•wet hands first with water (avoid HOT water)

•apply a nickel or quarter-sized amount of soap to hands

•rub hands together for at least 15-20 seconds

•cover all surfaces of the hands and fingers including under and around fingernails

•rinse hands with water and dry thoroughly

•use a clean paper towel to turn off water faucet

How to Wash Your Hands with Soap and Water

If hands are:

•not visibly soiled or contaminated with blood or body fluids,

•before and after having patient contact

•after touching equipment or furniture in a patients room

•after removing gloves

When should you use an

alcohol-based handrub?

•Apply nickel or quarter-sized amount of an alcohol hand rub to the palm of one hand, and rub hands together

•cover all surfaces of your hands and fingers

•include areas around/under fingernails

•use friction when rubbing hands together until alcohol dries

Alcohol hand rubs take less time than Soap & water.

How to Use an Alcohol-based Handrub

Isolation PrecautionsTB

• TB can be spread thru the air by coughing sneezing, (anything that makes it airborne)

• Latent TB means you are not sick, not infectious but you have a positive TB skin test.

• Symptoms of TB include, persistent cough, bloody sputum, night sweats, fatigue, anorexia, fever.

• You must wear a NIOSH approved mask to enter an occupied negative pressure room.

9

What is the Policy?

• No artificial fingernails, acrylic or gel enhancements, or any artificial applications.

• Keep natural fingernails clean and short (no longer than ¼ inch past fingertip).

• If nail polish worn, must be a single color of clear or clear light pink without ornamentation.

• Polish must not be chipped and must be changed at least weekly.

Applicable to :

ALL staff with patient contact including but

not limited to:

• Physicians

• Nursing Staff

• Dietary Staff

BBPs

• Pathogenic micro-organisms present in human blood that can lead to diseases

including:

• Human immuno-deficiency virus (HIV)

• Hepatitis B (HBV)

• Hepatitis C (HCV)

HIV

• A virus that leads to AIDS

• Depletes the immune system

• Does not survive long period of time outside the body

HBV

• Millions of Americans are chronically infected

• Symptoms include: jaundice, fatigue, abdominal pain, loss of appetite, intermittent nausea, vomiting

• May lead to chronic liver disease, liver cancer, and death

• Vaccination available to all employees

• HBV can survive for at least one week in dried blood

HCV

• HCV is the most common chronic

blood borne infection in the United States

• Symptoms: Generally same as HBV

• May lead to same chronic diseases as

HBV

• No vaccinations are given

• A person can be infected without any

symptoms

10

Potentially Infectious

Bodily Fluids

• Blood (per OSHA must be present to be a

BBP)

• Body Fluid such as:

Saliva

Vomit

Urine

Potential Transmission

Contact with another person’s blood or bodily fluid that contain blood

Mucous membranes: eyes, mouth, nose

(Know where eyewash

stations are located)

Non-intact skin

Contaminated sharps/needles

Universal Precautions

Treat all blood and bodily fluids as if

they are contaminated

Proper cleanup and

decontamination

Proper hand hygiene

Proper PPE

Protective Equipment

Bleeding control—latex gloves and any PPE needed to protect

you and your clothing (uniforms or street clothes are

not PPE)

Post accident cleanup—latex gloves

Janitorial work—latex gloves

Latex Free gloves are

available for latex allergic

Exposure Incident

• A specific incident of contact with potentially infectious bodily fluid

• If there are no infiltrations of mucous membranes or open skin surfaces, it is not considered an occupational exposure

• Report all exposure involving blood, bodily fluids or chemicals

• Post exposure medical evaluation

Performance Improvement

Guiding Points:• Customers always come

first- this is the primary

focus

• Utilize systematic problem solving techniques including involving experts in the area.

• No matter how good the process- variables will always exist!

11

Who are the customers?

•Patient

•Doctors

•Families

•Other staff members

•Vendors

•Regulatory agencies

•Many, many more!

Who are the experts?

•You are!

•The people doing the job know what needs to be done.

If it doesn’t feel right, report it.

Enjoy your clinical rotation at

Hugh Chatham Memorial hospital

Revised September 2013 by M. Simmons, Compliance Coordinator

Hugh Chatham Memorial Hospital

Code of Conduct (For Employees, Contract Employees, Volunteers, Students, Vendors & Board Members)

What rules do we need to follow?

√√√√ Federal Laws

√√√√ State Laws

√√√√ Local Laws

√√√√ Hugh Chatham Hospital

√√√√ Departmental Policies The following list includes THE MOST COMMON RULES Hugh Chatham Memorial Hospital must follow, but is not intended to include all laws that affect us.

� We will respect our patients’ rights at all times.

� We will provide only services that are medically necessary.

� We will document accurately and completely.

� We will not give or accept payment of any kind for the referral of patients.

� Each patient will be billed accurately.

� Patients referred for additional care must be given a choice of healthcare providers. We MUST disclose to patients any affiliations or relationships that Hugh Chatham Memorial Hospital has with providers or entities that they may be referred to.

� Every patient coming to the Emergency Room is entitled to a medical screening exam before we find out whether or not they can pay for their care.

� Patient information will not be shared except as necessary to provide healthcare or with written permission of the patient.

� Waste products will be disposed of according to Hugh Chatham Memorial Hospital written policy.

� Employees will use universal precautions when appropriate to protect themselves and others.

� Controlled substances will be dispensed and recorded as dictated by state and federal laws and Hugh Chatham Memorial Hospital Pharmacy policies.

� Hugh Chatham Memorial Hospital will set charges for services without discussion with our competitors.

� Hugh Chatham Memorial Hospital will pay reasonable fees for contracted services.

� Any gift, meal, or entertainment accepted from a vendor and valued over $25.00 will be reported to the Compliance Officer.

� Hugh Chatham Memorial Hospital will use only properly licensed software.

� Hugh Chatham Memorial Hospital will maintain a safe working environment.

Revised September 2013 by M. Simmons, Compliance Coordinator

� Employment decisions will not be based on race, color, sex, religion, age, national origin, ancestry, disability or sexual orientation.

� Fundraising for Hugh Chatham Memorial Hospital Foundation must not include false, deceptive or misleading statements. All printed materials must be approved through the Marketing Department.

� All advertising and printed materials will be approved through the Marketing Department.

� Employees and contractors will not accept tips or gifts from patients or physicians.

If you have any reason to believe we are not complying with any law or regulation, you must report your concern. You may:

→Tell your Direct Supervisor

→Tell your Department Manager

→Tell your Administrative representative

→Tell the Compliance Coordinator at ext. 8342

→Tell the Compliance Officer at ext. 7216

→Call the anonymous

Compliance Hotline: 1-800-340-5877

What should we do if a government investigator comes to visit us? Hugh Chatham Memorial Hospital is committed to obeying all local, state, and federal laws. Our Compliance Program is designed to make sure we do this. However, it is always possible that an investigator from the government will visit us. If a government official asks to talk to you:

♦Tell them you want to cooperate, but you want to call your Compliance Officer first. You do not have to talk to a government official without representation.

♦Call the Compliance Officer at 7216.

♦If you cannot get the Compliance Officer, call the Chief Financial Officer at 7216 or the Chief Executive Officer at 7312 or 7381. *Tell them you have a government investigator waiting to speak with you.

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(336) 527-7000 180 Parkwood Drive, Elkin, NC 28621 www.hughchatham.org

Our Region’s CHOICE for TECHNOLOGY & CARE

Confidentiality/Security Agreement

Name:_____________________________________________________ Job Title:___________________________________________________ Organization/Department:_____________________________________ Hire/Contract Date:_____________________ Employee #: ___________ PURPOSE OF AGREEMENT: Hugh Chatham Memorial Hospital is dedicated to preserving the privacy of patient information as well as other confidential organizational information. All individuals who have access to protected patient information in any format are accountable for protecting sensitive information as required by federal and state regulations and organizational guidelines. This agreement outlines general responsibilities with regard to ensuring the privacy and security of patients’ protected health information. BACKGROUND AND DEFINTIONS: The Health Insurance Portability and Accountability Act (HIPAA) was enacted in 1996 to protect patients’ privacy by providing guidelines for the dissemination and usage of individually identifiable health information, or Protected Health Information (PHI). The guiding rule for handling PHI in a compliant way is called “Minimum necessary.” In other words, access to and use of PHI is restricted to the minimum amount a staff member needs in order to perform his/her job. Confidential information includes – but is not limited to – the following:

• Demographic information (e.g. a patient’s name, DOB, SSN, address, phone number, etc) • Financial information (e.g. patient’s insurance policy number, account number, credit card, or

bank information, etc.) • Clinical Information (e.g. a patient’s admission and discharge dates, medical record number,

test results, medical chart, etc.) • Proprietary Information (e.g. information about departmental operations, business plans and

strategies, financial data, contract terms, personnel information, etc. Confidential information may be contained via any communication medium, including verbal, written, or electronic.

(336) 527-7000 180 Parkwood Drive, Elkin, NC 28621 www.hughchatham.org

Confidentiality/Security Agreement Please read and initial the following statements to indicate an agreement to use/disclose confidential information and maintain security in accordance with all applicable polices and regulations. Initials I agree to: Follow all regulations, policies, and department-specific procedures appropriate to my

role and responsibilities. Protect all confidential information from unauthorized access, download, use or

disclosure. Report and/or secure all confidential information found unattended or unsecured. Inform Supervisors and/or Compliance Officer of known or suspected instances of

unauthorized access, use, download, or disclosure of confidential information Keep passwords confidential and report any known or suspected instances of an

individual inappropriately using or sharing passwords. Make reasonable effort to only access the minimum amount of confidential information

needed to accomplish assigned tasks Safeguard all collected or generated confidential information in a manner that restricts

access to only those individuals with a need to know the information. Limit discussion of confidential information to necessary work-related communication in

private areas. Make a conscious effort to limit unauthorized individuals’ view or access to confidential

information in all forms of media, including electronic files, computer images, and hard copies.

Take reasonable efforts to limit exposure of computer screens containing confidential information to non-authorized individuals and “lock” the screen of the computer work station when unattended.

Dispose of papers or other items containing confidential information in accordance with established disposal processes (e.g., shredding) not in the trash.

Avoid removing any confidential information from the premises physically or electronically, without specific authorization and without appropriate precautions.

Initials I understand that any proven violation of this agreement may result in: Result in termination of access Disciplinary action Criminal prosecution under State and Federal Laws Signature ___________________________________________ Date: ________________________

HUGH CHATHAM MEMORIAL HOSPITAL, INC.

SAFETY ORIENTATION CHECKLIST

Student Name: ________________________Date: _________________________________________

Department(s): ______________________________________________________________________

Instructor or Dept. Manager: __________________________________

The following is a checklist of items that must be covered by the manager or designee of this departmentwith each new employee. Orient the new employee on the items listed and any others that may apply butare not listed.

FIRE PROTECTION REVIEWED N/A

Location of fire alarm pull stations ( ) ( )Location of emergency exits ( ) ( )Location of fire extinguishers ( ) ( )Use of fire extinguishers ( ) ( )Departmental fire plan ( ) ( )Evacuation procedures in case of fire ( ) ( )

HAZARD COMMUNICATION REVIEWED N/A

Hazardous chemical list for department ( ) ( )Chemical storage procedure ( ) ( )Chemical disposal procedures ( ) ( )Chemical container labeling procedure ( ) ( )Location – Hazard Communication Manual &

Materials Safety Data Sheets ( ) ( )How to read an MSDS – emergency procedures ( ) ( )

EMERGENCY PREPARDNESS REVIEWED N/A

Location & review of Hospital & department plan ( ) ( )Employee’s responsibility during disaster/drill ( ) ( )Evacuation procedures ( ) ( )Emergency telephone # and Code ( ) ( )

ELECTRICAL SAFETY REVIEWED N/A

Personal Electrical Equipment Policy ( ) ( )Location of panels and circuit breakers ( ) ( )Proper grounding procedures ( ) ( )

PERSONAL PROTECTIVE EQUIPMENT REVIEWED N/A

Location of protective equipment in the department ( ) ( )Personal protective equipment required ( ) ( )Conditions of work that require personal protectiveequipment ( ) ( )Location of hazardous spill kit ( ) ( )

GENERAL SAFETY REVIEWED N/A

Review of departmental policies and procedures ( ) ( )Wet floors, spills ( ) ( )Patient transportation procedures ( ) ( )Safe handling of compressed gas cylinders ( ) ( )Incident reporting procedures ( ) ( )Patient fall prevention ( ) ( )Work related injury/illness reporting procedures ( ) ( )

EQUIPMENT MANAGEMENT REVIEWED N/A

Orientation to equipment used in the department ( ) ( )Procedures for maintaining equipment condition ( ) ( )Equipment malfunction reporting procedures ( ) ( )Equipment operator’s responsibilities ( ) ( )Safe Medical Devices Act reporting procedures (SMDA) ( ) ( )Medical Device tracking procedures ( ) ( )Manufacturer’s recall policy ( ) ( )Procedures for using electrical equipment in gas-enriched environment ( ) ( )Equipment inspection procedures ( ) ( )

UTILITIES MANAGEMENT REVIEWED N/A

Procedures to be followed in case of electricalpower failure ( ) ( )Procedures to be followed in case of water failure ( ) ( )Procedures to be followed in case of oxygen failure ( ) ( )Procedures to be followed in case of suction failure ( ) ( )Reporting procedures for utility failure ( ) ( )Procedures to follow in case of air conditioningfailure ( ) ( )Lockout/Tag out procedures ( ) ( )

LIFE SAFETY MANAGEMENT REVIEWED N/A

Fire drill policy and procedures ( ) ( )Purpose of fire doors ( ) ( )Smoking policy ( ) ( )Interim (Code Alert) Life Safety Measures ( ) ( )Maintenance of EXIT corridors ( ) ( )Policy concerning door stops of fire doors ( ) ( )Restricted construction areas ( ) ( )

Manager or School Instructor: ___________________________________________________________

I acknowledge that I have received and understand the above information and have had the opportunity toask questions and have them answered.

Student: ________________________________________ Date: _______________________________

Schedule: _______________

College: _____________

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***X denotes completion of required information***

All forms/test/documents maintained at school. A copy of group passport and student schedule, and instructor verification must be submitted to

clinicalsite@hughchatham.org, originals maintained at school.

HCMH Group Passport for Clinical Student Groups >2Actions Taken - Forms Signed as Applicable

See Full Student Passport for Definitions of Health Requirements.

Instructor provided education

on: date

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on: date

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