Mountain States Health Alliance Observation Consent And Release Of Liability Form printable pdf download

Mountain States Health Alliance Observation Consent and Release of Liability Form

My observation experience is to be performed from (date) _______________________________________ during the hours of

________________ to _________________.

I understand that my observation experience will potentially expose me to communicable and infectious disease, injury from

needles and other sharp articles, slips and falls, and other unforeseen incidents.

I understand that if I am injured or exposed to communicable disease, or suspected of being injured or exposed to communicable

disease, I will be offered treatment according to Mountain States Health Alliance policy for such exposures and injuries. I will be held

responsible for the medical expenses related to all treatment that is provided to me in such instances.

Health Status Verification

I attest to the following:

I am immune to normal childhood diseases including rubella (German measles), rubella (measles), and varicella (chicken pox) either

by natural means (diagnosed, documented, and signed by licensed healthcare provider), immunity by laboratory results (positive

titer), or from vaccination (signed by licensed nurse or healthcare provider). These immunities are documented and will be

presented if requested to the site supervisor for purposes of audit, regulatory survey, and/or as part of epidemiologic investigation

related to communicable disease exposure.

I am free of significant eye, skin, respiratory, gastrointestinal, or other communicable infections. This includes fever, cough, cold,

cold sores, hepatitis A, lice, scabies, diarrhea or recent exposure to communicable infections such as chicken pox (varicella),

pertussis (whooping cough), or Tuberculosis (TB).

I am free of any skin rashes, including any reaction to recent chicken pox vaccination.

I understand that if I become sick (including but not limited to fever, cough, diarrhea, vomiting, cold or flu), I will remove myself

from any hospital assignment, seek medical care as appropriate, and will not return with any communicable disease.

Other Infection Control Instructions:

I must comply with hand hygiene procedures by using soap and water/hand sanitizers before and after entering any patient room or

treatment area, eating, and after using the restroom.

I hereby release this organization, its employees, its agents and its medical staff and agree to hold them harmless from any and all

actions and claims, not caused by their negligence, arising out of their good faith performance under this consent document.

Unpaid Experience:

My signature acknowledges that my observation does not constitute an implied promise of future employment, and I understand

that this observation experience is unpaid. I have read this form carefully before signing it, as well as the Mountain States Health

Alliance Expectations for Observation Experiences form, and have been given the opportunity to ask questions relating to my

observation experience.

By signing below, I consent to all terms presented and associated with Observing at Mountain States Health Alliance.

___________________________________

____________________

Name of Person Requesting Observation (Print)

Signature

Date

___________________________________

____________________

(If under 18 yrs old) Parent/Guardian Name

Signature

Date

Revised 2/20/15

Mountain States Health Alliance Observation Consent And Release Of Liability Form