Jr Hospital Of Cook County - University Of Illinois (Page 3 of 4) in pdf

John H. Stroger, Jr. Hospital of Cook County

Cook County Health & Hospital System

(formerly Cook County Bureau of Health Services)

HEALTH PROFESSIONS STUDENT

INDIVIDUAL AGREEMENT FOR LIMITED CLINICAL OBSERVATION/TRAINING

(“Student”), hereby represent that, in consideration of being granted permission to observe

and, if authorized by the applicable Hospital Supervisor, to participate in supervised patient care at Stroger Hospital of

Cook County (“Hospital”), located at 1901 West Harrison Street, Chicago, Illinois, hereby agree to the following terms

and provide the following information, understanding that the County and its Hospital are relying upon such information

and upon such agreement:

Date of Birth and Residence. My date of birth and current residence are as follows:

__________________________________________________________

School/Program Affiliation. I am a current student in good standing at the following school and am enrolled in

an accredited educational program in a health profession as follows:

_________________________________

Health Care Discipline

College Name and Address

Assignment. I request permission to observe the provision of health care to patients at Hospital in the

department on

(dates) and to participate in supervised

patient care activities upon being expressly instructed to do so by my Hospital supervisor.

Student Supervision. I understand that I have status of trainee and may render patient care or other services only

under direct supervision and as directed by my Hospital supervisor, an individual who shall be designated by the

head of the department listed in paragraph (3) above. I agree to abide by all Hospital policies and procedures

while on site at the Hospital. I understand and agree that the Hospital retains full authority and responsibility for

patient care at the Hospital and that either the department head or my Hospital supervisor may at any time

terminate my participation in Hospital activities.

Identification. While on the Hospital premises, I shall at all times exhibit an appropriate identification badge

furnished by the Hospital which I shall return to the Hospital at the

conclusion of the assignment. I shall identify myself to Hospital patients and staff in accordance with Hospital

procedures.

Health Requirements: I have provided the following documentation to the Hospital’s Department of Planning,

Education and Research Office prior to my participation in activities at Hospital:

Proof that I received the Hepatitis B Vaccination and other vaccinations that may be required by the

Hospital;

Proof of Tuberculosis (TB) screening within one year of my participation in activities at Hospital.

Further, I represent that I am in a condition of health which enables me to participate safely in patient care

activities at the Hospital, subject to the following limitations:

________________________________________________________________________ .

7..

Emergency Medical Care. I give my permission for the Hospital to provide emergency medical care and

treatment in the event of injury and illness occurring at the Hospital. I understand that I am responsible for the

expense associated with such treatment.

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