Student Training Pharmacy & Nursing

Williamson Health Observations

You must be 16 years or older to observe
The Williamson Health observation program is provided as a service to our community. The program allows local students, potential hires, and current staff the opportunity to observe a medical career path of interest.

There is a limited amout of observation time allowed per student based on department, availabity, and time allowances.

We are unable to set up observations in certian areas due to patient safety and infection prevention concerns (ie lab).

Please note, preferences for scheduling a observation day will be considered however, organizational priorities may take precedence as needed.

Please allow us up to two weeks after we receive ALL of your paperwork to schedule an observation.

You should not show up to Williamson Health until you are approved to do so.

Day of arrival: you will enter via the Boyer/Bryan tower and go to the Security desk to check in and they will confirm that you are on the calendar and give you an observation badge. The plastic badge holder must be turned in at the end of each day. You will sign in and out for the day

Dress Code:

Male & Female Dress: Wear khaki’s/navy, black slacks with polo shirt, button down shirt/blouse, and comfy shoes! No suits and not scrubs. Wear comfortable shoes!

Williamson Health is located at 4321 Carothers Parkway
Name (provide legal first name)

First NameLast Name
Age:
Email
example@example.com
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 1

First NameLast Name
Emergency Contact 1 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 2

First NameLast Name
Emergency Contact 2 Phone
Please enter a valid phone number.Format: (000) 000-0000.
For our student observers:
Select up to 3 Observation Picks:

If you are a job shadow or internal employee and know the department or unit please select "other" and type in the specific department in the second box.
List other here:
Please list your availability for the requested observation so that we can contact the Department for approval. No weekend dates are available.
Preferred Date for Observation

Please note it may take up to 2 weeks to schedule requests once your paperwork has been sumbitted
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Parking Form
Parking Information- put NA if you are not driving yourself or you are a current employee
Print the parking form for your reference:

TB Risk Assessment & Symptom Evaluation- please type your full name
Temporary or permanent residence of greater than or equal to 1 month in a country with high TB rate. Any country other than the United States, Australia, New Zealand, Northern or Western Europe.
Current or planned immunosuppression. Including human immunodeficiency virus (HIV) infection, organ transplant recipient, treatment with a TNF-alpha antagonist (e.g. infliximab, etanercept, or other), chronic steroids (equivalent of prednisone greater or equal to 15mg/day for greater or equal to 1 month) or other immunosuppressive medication.
Close contact with someone who has had infectious TB disease since the last TB test.
Productive, persistent cough lasting 2-3 weeks in duration?
Blood in sputum?
Night Sweats?
Weight loss not caused by dieting?
Fatigues, tires easily?
Unexplained fever or shortness of breath?
If "Yes" to any question, please explain:
My signature below indicates that my TB Risk Assessment is accurate:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Handwashing Agreement
Hand hygiene protects both healthcare personnel and patients. Hand hygiene means:

· Handwashing with soap and water (e.g., plain soap or with an antiseptic).

· Antiseptic hand rub (alcohol-based foam or gel hand sanitizer).

· Surgical hand antisepsis.

Cleaning your hands reduces:

· The potential spread of deadly germs to patients.

· The spread of germs, including those resistant to antibiotics.

· The risk of colonization or infection from germs received from the patient.

Hands should be cleaned:

· Immediately before and after patient interaction

· Before, during, and after preparing food or eating

· Before and after treating or touching a cut or wound

· After using the toilet

· After blowing your nose, coughing, or sneezing

· After touching hospital surfaces (elevator buttons or door handles etc)

· After handling garbage
Handwashing Attestation: I agree to wash my hands and use alcohol-based foam while observing at Williamson Health. I understand that failure to comply with the handwashing protocol can result in termination of my observation experience. My signature below indicates my understanding of the guidelines.
Signature:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Observation & Confidentiality Form
I hereby request to observe for an eight (8) hour timeframe within Williamson Health with a designated individual. I understand I may not assist in patient care activities and I am not, at any time, considered an employee or agent of Williamson Health. I understand I am expected to adhere to the behavior and dress code expectations given to me, follow the instructions of the Physician or Williamson Health staff whom I am observing, and to cooperate with the staff with whom I am assigned.

In order to respect the privacy of the patients or other confidential information gained from my observation at Williamson Health (WH), including Bone & Joint Institute of Tennessee (BJIT) and Williamson Medical Group (WMG), I agree not to share with others any private and/or confidential information as a result of this observation and maintain confidentiality of all patients and their health information which I may encounter while observing within the facility. Any unauthorized viewing, discussion or disclosure of confidential information will provide grounds for immediate termination of the observation experience. These confidential guidelines are based on information defined in the Health Insurance Portability and Accountability Act (HIPAA).

I understand I am assuming all risks of any nature whatsoever and do hereby release and forever discharge Williamson Health, its officers, directors, employees, and agents from claim of liability for any injury/accident occurring on the premises of Williamson Health. I understand I am not afforded protection under Williamson Health’s worker’s compensation or health insurance program.
No individual will be discriminated against on the basis of race, sex, religion, color, national origin or ethnic origin, age, disability, genetic information, sexual orientation, gender identity or expression, military services, or other basis prohibited by law.
Signature (must be signed by parent if student is a minor)
Printed Name of signee:

First NameLast Name
Flu Shot Attestation:
Please indicate below your flu shot status (November 1st- March 30th)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
YOU MUST: ***(1.) Download the certificate for required training and (2.) signed Observation & Confidentiality Form and (3.) Flu declination form - if you are NOT getting the vaccine***

Cancelof
Should be Empty:

Williamson Health Observations

Select up to 3 Observation Picks:

Preferred Date for Observation

Parking Form

Handwashing Agreement

Observation & Confidentiality Form

Flu Shot Attestation: