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Student / Intern Acknowledgment of Policies & Procedures

Directions

Click the first policy below to review. After review, click the "Back" arrow and click on the next policy to review. When finished, click "Back" arrow to finish the acknowledgment form.

 

Confidentiality Policy Agreement                                                       

As a student or intern with Scotland County Health Department (SCHD), I agree to comply with all confidentiality policies and procedures set in place. I realize that it is privileged information and is not to be shared with anyone other than a current employee of Scotland County Health Department and ONLY in an official capacity. If I, at any time, knowingly or inadvertently breach the patient confidentiality policies and procedures, I must notify the Health Director or the agency’s HIPAA Officer immediately. Also, per General Statue 130A-143, I agree that all information and records, whether publicly or privately maintained, that identify a person who has the AIDS virus infection or who has or may have a disease or condition required to be reported pursuant to the provisions of this Article shall be strictly confidential. I understand that any violation of this agreement or Scotland County Health Department’s policies related to access, use or disclosure of confidential information may result in significant legal ramifications for which I will be held solely responsible with respect to this Agreement.     

Furthermore, I also give Scotland County Health Department permission to reproduce pictures or news articles pertaining to my service in the agency, as long as it is not a confidential matter.  I understand that I am obligated to report any solicitation for confidential information to my supervisor. By my initials and signature below, I have read and understand, and have been given the opportunity to ask questions regarding the Scotland County Health Department Confidentiality Policy.

Dress Code Policy Acknowledgment

I have read and have been informed about the content, requirements, and expectations of the Dress Code policy for students and interns for Scotland County Health Department. I agree to abide by the policy guidelines as a condition to continue my clinical rotation or internship. I understand that if I have questions, at any time, regarding the Dress Code policy, I will consult with my immediate preceptor, department coordinator, supervisor or department Human Resources representative

Consent to Seek Medical Care

I authorize the SCHD to seek emergency medical care, on my behalf, as needed.  I understand and agree to allow the SCHD to use their best judgment, in the event that medical assistance as needed.  The staff and the SCHD will be held harmless for any and all results of the staff’s efforts to obtain emergency medical treatment including any accident or injury while being transported.

Consent to be Transported

I understand and agree that the staff and the SCHD will be held harmless in any accident or injury to me while participating and transported to and from program activities.

Accidents and Injuries

I understand and agree that the SCHD, Scotland County and staff will be held harmless in any accident or injury to me while I participate in program activities as a student or intern.  Furthermore, I verify that I have health and/or accident insurance and will provide a copy to SCHD.

Safety Orientation:

Please watch the following YouTube video on Health Care safety in the workplace.

I have watched the above video on healthcare safety and understand the hazards I may encounter.  If I have questions or concerns about these hazards, I will discuss them with my supervisor or agency Safety Officer.

Student / Intern Signature

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