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Revised 4/9/14 15-9046-0
Security and Confidentiality Agreement
Print Name
Signature
Entity or Department
Date Badge # or UF ID #
*For purposes of this agreement, UF Health includes the University of Florida Board of Trustees for the benefit of the University of Florida College of Medicine, Shands Jacksonville Medical Center, Inc., and Shands Teaching Hospital & Clinics, Inc.
UF Health* has a legal responsibility to safeguard the confidentiality and security of our patients’ protected health information (PHI) as well as operational, proprietary, and employee information. This information may include, but is not limited to, patient health records, human resources, payroll, fiscal, research, and strategic planning and may exist in any form, including electronic, video, spoken, or written. This agreement applies to all members of the workforce, including but not limited to, employees, volunteers, students, physicians, and third parties, whether temporary or permanent, paid or not paid, visiting, or designated as associates, who are employed by, contracted to, or under the direct control of UF Health. This agreement also applies to users of UF Health* information systems and the information contained therein, whether the user is affiliated with UF Health or not, and whether access to or use of information systems occurs locally or from remote locations. I hereby agree as follows:
• I acknowledge that UF Health has formally stated in policy its commitment to preserving the confidentiality and security of health information in any format. I understand that I am required, if I have access to such health information, to maintain its confidentiality and security.
• I understand that access to health information created, received, or maintained by UF Health or its affiliates is limited to those who have a valid business, medical, or professional need to know the information. I understand that UF Health has implemented administrative, technical, and physical safeguards to protect the confidentiality and security of PHI, and I agree not to bypass or disable these safeguards.
• I understand that I will be given a unique User ID and password to access electronic health, operational, proprietary, employee or other confidential information. I understand that my User ID and password are confidential, that I am responsible for safekeeping my password, that I am also responsible for any activity initiated by my User ID and password, and that in certain circumstances my User ID and password may be equivalent to my legal signature. If I suspect that my User ID or password has been compromised, I should immediately contact UF Health IT.
• I have no expectation of privacy when using UF Health information systems. UF Health shall have the right to record, audit, log, and/or monitor access to or use of its information systems that is attributed to my User ID. I agree to practice good workstation security measures on any computing device that uses or accesses a UF Health information system. Good security measures include, but are not limited to, maintaining physical security of electronic devices, never leaving a device unattended while in use, and adequately shielding the screen from unauthorized viewing by others.
• I understand that only encrypted and password protected devices may be used to transport PHI or other Restricted Data.
• I understand that smartphones and other mobile devices used to access UF Health information systems must be configured to encrypt any Restricted or Sensitive Data, including photographs and videos, in persistent storage. I understand that I may access and/or use UF Health confidential or Restricted Data only as necessary to perform my job-related duties and that I may disclose (i.e., share) confidential or Restricted Data only to authorized individuals with a need to know that information in connection with the performance of their job functions or professional duties.
1. Restricted Data: Data in any format collected, developed, maintained, or managed by or on behalf of UF Health, or within the scope of UF Health’s activities, that are subject to specific protections under federal or state law or regulations or under applicable contracts (e.g., medical records, Social Security numbers, credit card numbers, Florida driver licenses, and export controlled data).
2. Sensitive Data: Data whose loss or unauthorized disclosure would impair the functions of UF Health, cause significant financial or reputational loss, or lead to likely legal liability (e.g., financial information, salary information, hospital policies, research work in progress, and copyrighted or trademarked material).
• I understand that upon termination of my employment / affiliation / association with UF Health, I will immediately return or destroy, as appropriate, any confidential or Restricted Data in my possession. I understand that my confidentiality obligations under this Agreement will continue after the termination of this Agreement and after termination of my employment or affiliation with UF Health.
• I agree to immediately report any known or suspected violation of the confidentiality or security of PHI of patients of UF Health to either UF Health IT or to the UF Health Privacy Office.
• I understand that violations of this Agreement may result in revocation of my user privileges and/or disciplinary action, up to and including termination, and that UF Health may seek any civil or criminal recourse and/or equitable relief.
h By signing or by entering my name and other identifying information on this Agreement, I acknowledge that I have read this Agreement and agree to comply with all the terms and conditions stated above.
College of Medicine PO Box 100216 Office of Student Affairs Gainesville, Florida 32610-0216
Telephone: (352) 273-7971 Fax: (352) 627-4260
Non-degree Registration Request
Term and year of: Fall – August _____ Spring – January _____ Summer A/C – May _____ Summer B – June _____ (This form is valid only for term indicated)
UFID – This will be your official student number as assigned by the university. _____________
Exact legal name: __________________________________________________________________________________ Last/Family First Middle
Gender and ethnic background information are requested by federal regulation and will not influence your registration in any way.
Gender: Male _____ Female_____ Transgender Male _____ Transgender Female _____ Non-binary _____ Other _____ Prefer not to answer _____
Ethnic Background: Asian or Pacific Islander _____ American Indian or Alaskan Native _____
Black (not Hispanic) _____ White (not Hispanic) _____ Hispanic _____
Gender and ethnic background information are requested by federal regulation and will not influence your registration in any way.
Date of Birth: ______________________________ Month Day Year
Nation of citizenship: ______________________________ Non-U.S. only ___ Resident Alien ___ Alien ___
Local phone number: ______________________________
Current Address: __________________________________________________________________________________ Number and Street City Country State Zip Code
Permanent Address: ________________________________________________________________________________ Number and Street City Country State Zip Code
E-Mail address: ______________________________
What is the highest degree you currently hold?
None _____ High School Diploma _____ Associate of Arts _____ Associate of Science _____ Bachelor’s _____ Engineer _____ Master’s _____ Specialist_____ Ed.D _____ Ph.D. _____ Professional (JD, MD, DMD, DDM, DDS, DVM) _____
High school attended: ___________________________________________________________________________________________________ Name City State
Last postsecondary institution attended: ___________________________________________________________________________________________________ Name City State
Have you previously attended the University of Florida in any capacity?
Yes ___ No ___ Term _______________
Are you currently enrolled at another institution? Yes ___ No ___
Have you ever applied for regular admission to the University of Florida? Yes ___ No ___
Are you in good standing and eligible to re-enter your last-attended college of university? (Students not in good standing or under suspension from any institution may not register for non-degree coursework).
Has any court or school authority found you to have disrupted or interfered with the orderly conduct, processes, functions or pogroms of any educational institution? Yes ___ No ___ If yes, please provide details:
Are you currently charged or have you ever been convicted of a crime (even if adjudication was withheld) other than offenses involving $50 or less? Yes ___ No ___ If yes, please indicate date, name of court, nature of offense and penalty imposed:
___________________________________________________________________________________________
___________________________________________________________________________________________
I understand that this application is for the term indicated only and does not imply acceptance for a future term. I certify that the information on this application is complete and accurate, and I understand that to make false or fraudulent statements within this application or residency affidavit may result in disciplinary action and invalidation or credits earned. If permitted to register, I hereby agree to abide by the policies of the Florida Board of Education and the rules and regulations of the University of Florida.
_____________________________________________________________________ _______________ Student Signature Date
Purchasing Insurance
Proof of personal health insurance (copy of your current insurance card) and proof of professional liability insurance coverage (with minimum limits of $1,000,000 per occurrence, $3,000,000 aggregate) is mandatory.
• If the home institution provides professional liability coverage for the student at therequirement limits, the signed UF Professional Liability Insurance Verification form issufficient.
• If the home institution does not provide professional liability coverage, the student mustpurchase their own coverage and submit a copy of the certificate or policy along with the UFProfessional Liability Insurance Verification form. Documents must be submitted prior to thestart of the rotation.
The companies listed below offer the required liability insurance coverage. It is the students’ responsibility to contact them and purchase the coverage required for participation in the rotation.
Below is a list of carriers offering student insurance. Without these approved policies, you will not be permitted to participate in a rotation at the University of Florida College of Medicine.
• The Academic Medical Professionals Insurance Rick Retention Group, LLC offers professionalliability coverage only so you would need to obtain general liability coverage elsewhere.
https://www.academicgroup.com/ampi-for-med-students.html
• The companies below should offer professional liability and/or general liability policies formedical students.
• Healthcare Professional Services, Inc.HPSI-INS.COMPh. 678-935-5040
• Medical professional and general liability insurancewww.einsurance.comPhone: 877-907-5267
• Commercial Insurance CenterGeneral liability coveragePhone: 339-215-8321
Professional Liability Insurance Verification
for Visiting Students Q&A
1) For purposes of executing this document, who qualifies as an official at the HOME INSTITUTION?
Although we defer to the HOME INSITUTION in deciding who has the authority and control to execute this document on behalf of the HOME INSTITUTION, we would prefer that one individual in each college (e.g., Dean, Dean’s designee, GME Director) be appointed as the official for document execution. This will help to ensure consistency in approach, understanding, and completion.
2) What are the coverage requirements if the home institution is a non‐Florida state university but IS a publicentity entitled to governmental immunity protections under state law?
If the HOME INSTITUTION is a public entity entitled to governmental immunity protections under applicable state law, then the HOME INSTITUTION will need to attest that it provides Occurrence‐Based, or Claims‐Made with tail coverage that includes the rotation dates, professional liability coverage in accordance with any limitations associated with their applicable state law. In addition, the HOME INSTITUTION will need to attest that it also provides such insurance with limits of no less than $1,000,000 per occurrence/$3,000,000 annual aggregate in the event governmental immunity protections are determined by a court of competent jurisdiction not to apply.
VISITING STUDENTS/UF SIP | 7.30.2021 P a g e 1 | 2
1) For purposes of executing this document, who qualifies as an official at the HOME INSTITUTION?
3) When must a Certificate of Insurance accompany this form?
If the HOME INSTITUTION does not provide protections for their students, and is attesting that the student has personal professional liability insurance with limits of at least $1,000,000 per occurrence/$3,000,000 annual aggregate, a certificate of insurance demonstrating required coverage must accompany this form when submitted to the UF SIP.
Professional Liability Insurance Verification for Visiting Students
** This form is to be completed by an official at the student’s home institution. **
I certify that (name of student) is in good standing at (name of HOME INSTITUTION)
, and has received my approval to participate in the
following rotation(s) at UF Health and its affiliated hospitals and/or clinics:
Name of Rotation(s):
Rotation Facility Name:
Dates of Rotation(s):
During the student’s participation in the rotation, the following applies to professional liability coverage (select one):
A. Florida state university and college system students (as set forth in s. 1000.21(3)(6), Florida Statutes*):
The HOME INSTITUTION warrants and represents that it is a public entity entitled to governmental immunity protections under applicable state law and that it provides occurrence‐based professional liability insurance for its students in accordance with section 768.28, Florida Statutes; but, the HOME INSTITUTION also warrants and represents that it provides such insurance with limits of no less than $1,000,000 per occurrence/$3,000,000 annual aggregate in the event governmental immunity protections are determined by a court of competent jurisdiction not to apply.
B. Non‐Florida state university and college system students (as set forth in s. 1000.21(3)(6), Florida Statutes*):
The HOME INSTITUTION warrants and represents that it provides Occurrence‐Based, or Claims‐Made with tail coverage that includes the rotation dates, professional liability insurance, or self‐insurance, that covers the student during the rotation with limits of no less than $1,000,000 per occurrence/$3,000,000 annual aggregate.
‐ OR ‐
The student warrants and represents that he/she has occurrence‐based, or Claims-Made with tail coverage that includes the rotation dates professional liability insurance with limits of at least $1,000,000 per occurrence/$3,000,000 annual aggregate. A certificate of insurance demonstrating coverage described herein must accompany this form when submitted to the UF SIP.
Signature: Title: School Official at Student’s Home Institution
Printed Name: Date:
School: Phone #:
Email Address: Fax #
Mailing Address:
*State universities, set forth in s. 1000.21(6), Florida Statutes, are:
University of Florida Florida State University Florida Agricultural and Mechanical University of South Florida
Florida Atlantic University University of West Florida University of Central Florida University of North Florida
Florida International University Florida Gulf Coast University New College of Florida
Florida Polytechnic Institute
*Florida College System Institutions, set forth in s. 1000.21(3) Florida Statues, can be found at the following link: http://www.leg.state.fl.us/statutes/
VISITING STUDENTS/UF SIP | 7.30.2021 P a g e 2 | 2
Section A: Required Immunizations Information *Please note: All titers must include a lab report*
1. MMR / MEASLES, MUMPS, RUBELLA VACCINE:Required for everyone born after Dec. 31, 1956. Two doses are required. You must havereceived on or after 12 months of age AND in 1971 or later. The second dose must havebeen received at least 30 days after the first dose. OR Provide lab evidence of immunity bydoing a blood test to check for antibodies for Measles, Mumps and Rubella. If you do ablood test, you need to provide the results on a lab form that should be faxed or mailedwith the completed Mandatory Immunization Health History Form.
2. HEPATITIS B VACCINE:Students are required to receive this vaccination. Three dose series are required. You mustget the first dose prior to start of classes.
3. MCV4 (MENACTRA/MENVEO) / MENINGOCOCCAL MENINGITIS VACCINE:The Advisory Committee on Immunization Practices (ACIP) currently recommends thisvaccine for freshmen planning to live in campus dormitories/residence halls. Students arerequired to receive this vaccination OR read the CDC’s Vaccine Information Statement andsign where indicated on the Form to decline. Read the VIS here:https://www.cdc.gov/vaccines/hcp/vis/vis-statements/mening.html. Signing the waiverindicates you understand the possible risk in not receiving this vaccine.
4. TD or/and TDAP VACCINE:Td (Tetanus/Diphtheria) or/and Tdap (Tetanus/Diphtheria/Pertussis):Tdap = Adacel/Boostrix.Booster shot within last 10 years. May have TD but must have at least one instance of Pertussis.
5. VARICELLA (CHICKENPOX):Provide proof of two doses of Varivax OR provide results of a blood test on a lab formverifying immunity to Chickenpox/Varicella. All titers must include the lab report.
6. TUBERCULOSIS SCREENING:Required for All Students. Refer to the grid below to determine appropriate timeframe forTB Screening and type of testing required. If either screening is returned positive, then youmust get a chest x-ray and submit a copy of the report.
FOR TST (Mantoux): The result of the TST needs to be recorded in mm in the spaceprovided on the form and whether considered negative or positive.
For Interferon-based Assay, IGRA, (QFT or Tspot): You must submit the lab report.
COLLEGE PRIOR TO CLASS START ACCEPTED TEST TYPE(S) Dental Within 12 months TST (must complete 2-step) or IGRA Medicine/DAT Within 12 months TST or IGRA PA Within 12 months TST (must complete 2-step) or IGRA Nursing Within 12 months TST or IGRA Pharmacy Within 12 months TST or IGRA PHHP Within 12 months TST or IGRA
Basic Instructions: DO NOT WAIT! Submit documents
prior to orientation or registration. Late, incomplete or inaccurate information will prevent course registration.
Include UFID on all correspondence. Print all student information legibly (name, phone, etc.).
Keep a copy for your records.
Check UF account to see if the immunization checklist has been cleared: one.uf.edu. Health Compliance does not send confirmation that an individual form has been received.
How to Submit: [email protected]
FAX:(352) 627-4260Please do not include a cover sheet or other pages that are not required.
MAIL:College of Medicine Office of Student AffairsP.O. Box 100216Gainesville, FL 32610-0216
**Please note: Email sent over the Internet is not necessarily secure. Please be aware that the University of Florida (UF) Health Compliance Office and the UF Student Health Care Center (SHCC) cannot guarantee the confidentiality or security of any information sent over the Internet when using email. UF and/or the SHCC shall not be liable for any breach of confidentiality resulting from such use of email via the Internet.
Mandatory Immunization Health History Form HEALTH PROFESSIONS
REQUIRED – UFID NUMBER (8 digits):
- Name: _________________________________________ Date of Birth: _______________________ Phone: ________________________
Health Profession (check one): Dental DAT Medicine PA Nursing Pharmacy PHHP
Vaccine Name Date (MM/DD/YYYY)
Date (MM/DD/YYYY)
Date (MM/DD/YYYY)
Titer Date & Result (Must include lab report)
1. MMR (Measles, Mumps, Rubella)(2 doses on or after 12 months of age)
--NOT APPLICABLE--
2. Hepatitis B
3. MCV4 (Menactra/Menveo) --NOT APPLICABLE-- --NOT APPLICABLE--
I have read the information about MCV4 (Menactra/Menveo) / Meningococcal Meningitis and decline receipt of this vaccine.
____________________________________________________________________________ _____________________ Student Signature Date
4. Td and/or Tdap (Adacel/Boostrix) (Must have one instance of pertussis)
--NOT APPLICABLE-- --NOT APPLICABLE--
5. Varicella (Varivax) --NOT APPLICABLE--
6. Tuberculosis Screening: (see instructions on p.1)
TB Skin Test by TST (Mantoux)
#1 Date Placed Date Read MM
Result: Neg Pos
#2 Date Placed Date Read MM
Result: Neg Pos
OR Interferon-based Assay (QFT or Tspot) Date Result
Submit copy of lab report
Chest X-ray (Only if positive TST or Lab Test) Date Result
Submit copy of x-ray report
SECTION B: Optional Immunization
COVID-19
Moderna --NOT APPLICABLE--
Pfizer --NOT APPLICABLE--
J&J --NOT APPLICABLE--
Important! Make a copy of this page and all lab reports to keep for your records. An official stamp from a doctor’s office, clinic or health department AND an authorized signature must appear here or this form will not be approved.
_________________________________________________ __________________________________ _________________________ Official Office Stamp Here Physician or Authorized Signature Date
EMAIL: [email protected]| FAX: (352) 627-4260 (No cover sheet) | MAIL: COM Office of Student Affairs, P.O. Box 100216, Gainesville, FL 32610-0216
OFFICE USE ONLY
MRN:________________________
Health Professions Immunization Form
College of Medicine Office of Student Affairs
PO Box 100216 Gainesville, Florida 32610-0216 Telephone: (352) 273-7971 Fax:
(352) 627-4260
AFFIDAVIT
I , of Name of Student Address
Swear or affirm the following:
1. I have had no incidents of criminal behavior since the local state background check that was completed andconfirmed on.
DATE of background check
2. I have had no incidents of criminal behavior since the national background check that was completed andconfirmed on.
DATE of background check
3. I have not taken any illegal substances since the drug screen that was completed and confirmed on.
DATE of drug screen
I understand that I am obligated to notify the University Of Florida College Of Medicine of any incidents of criminal behavior or drug use prior to or during my requested rotation. I further understand that the University of Florida College of Medicine has the right to remove me from my requested rotation at any time.
Sworn to and subscribed before
me this
day of ,
Signature of Student
Signature of Notary
An Equal Opportunity Institution
