Request to Shadow a University of Utah Health Workforce Member

Request to Shadow a University of Utah Health Workforce Member

This experience allows approved individuals to observe a University of Utah Health workforce member for a maximum of 12 hours per department per year. Before filling out this form, applicants must communicate with the individual they intend to shadow (sponsor) or someone coordinating the experience on their behalf.

Please note: Shadowing does not meet the requirements for patient exposure or practicum experiences. Patient exposure is defined as direct interaction with patients and hands-on involvement. As a shadower, you will be strictly limited to observing patient care and will not participate in patient care in any other way.

If you are currently attending a program where clinical training hours are required for graduation, please do NOT submit this form. For further assistance, e-mail studentplacement@hsc.utah.edu.

Your Information

Individual applying for Shadow experience

First Name*

Last Name*

E-mail*

Are you a physician?*

Yes

Who is your contact at University of Utah Health?

Sponsor = The employee you will be shadowing

Coordinator = Department representative who is assisting you in the approval process and pairing you with a sponsor

If you do not already know a sponsor or department who has agreed to host you, we cannot facilitate pairing you with a sponsor or shadowing experience.

Please select one (see definitions above)*

I know my sponsor only

I am working with a coordinator who will pair me with a sponsor

I know both my sponsor and coordinator

Sponsor*

Name of University of Utah Health Employee who you will be shadowing.

Sponsor's E-mail*

Coordinator Name*

Name of the individual helping coordinate your shadow experience

Coordinator E-mail*

Shadow Date*

Estimated date if exact date is unknown

Department*

Department you will be shadowing (eg. Physical Therapy, Cardiology)

Location

Specific location of training (eg. South Jordan Health Center, E50)

Are you a current employee of University of Utah Health or a current Medical Student at U of U?*

Pre-med students must select "No" unless they are also current employees.

UID*

Please enter your UID. Upon verification, we will waive your immunization & HIPAA requirements as we can verify these with HR.

Birthdate*

Immunizations

To Shadow, you must be current on the following immunizations. If you do not have sufficient records, please obtain them from your provider or health department before submitting this shadow request.

Please closely review your immunization documents to answer the questions below and enter the dates. We will review the documents you upload.

University of Utah students may utilize immunization services at the Student Health Center.

Measles*

I have documentation of two measles immunizations (MMR)

I have documentation of a measles titer that proves immunity

MMR2*

MMR1*

Measles Titer*

Varicella*

I have documentation of two chickenpox (varicella) immunizations.

I have documentation of a varicella titer that proves immunity.

Varicella1*

Varicella2*

Varicella Titer*

Tdap*

Date of most recent Td or Tdap immunization. Must be within the past ten years.

Tuberculosis test*

I have documentation of a negative TST (Two-step TB Skin Test) within the past year.

I have documentation of a negative Quantiferon Gold or T-spot blood test within the past year.

I have documentation of a negative chest x-ray within the past year.

TB Test Date*

Please enter the date of your negative skin test, blood test, or chest x-ray.

Influenza*

If your shadow date is between October and May, you must provide documentation of an influenza immunization (from the current season). Please enter the date of your most recent Flu shot.

File Upload*

Please upload your immunization records consistent with the above dates. We will review these documents and request any additional documentation via e-mail.

Drag and drop files here or

HIPAA Privacy & Security Training

Access the following website, review the slides, and sign the attestation below. https://healthcare.utah.edu/media/16681

I attest that I have successfully completed the assigned HIPAA course of study required by University of Utah Health for Vendors, Shadowers and Visiting Students and will comply with the HIPAA Privacy and Security Regulations and University of Utah Health Policies and Procedures.*

(Type full name below)

VISITOR CONFIDENTIALITY AND NON-DISCLOSURE AGREEMENT

This Confidentiality and Nondisclosure Agreement (“Agreement”) is made by the individual whose name and address is set forth below (“Visitor”). This Agreement applies to any information obtained by Visitor while at the University of Utah Health (“U of U Health”).

As used in this Agreement, “Confidential Information” includes, but is not limited to: (a) hospital medical records; (b) clinic medical records; (c) physician's private patient records; (d) medical records received from other health care providers; (e) correspondence addressed to or from workforce members of the U of U Health concerning a specific, identifiable patient; (f) patient information verbally given to me by the patient or other persons; (g) diagnoses; (h) assessments; (i) medical histories; (j) operative reports; (k) discharge summaries; (l) nursing notes; (m) medications; (n) treatment plans; (o) follow-up care plans; (p) requests for and results of consultations; (q) results of laboratory, radiologic, or other medical tests; (r) demographic data; (s) financial/funding information; and (t) all other types and categories of information to which I know or have reason to know the U of U Health intends or expects confidentiality to be maintained in any form - written, verbal, electronic, or printed.
Visitor shall not disclose any Confidential Information to any other party or person (except an authorized U of U Health employee with a “need to know”) at any time, whether during or after the visit to U of U Health.
Visitors accessing U of U Health information shall access only the information for which they are authorized. The individual understands that accessing unauthorized information may subject them to the Utah Computer Crimes Act. This Act makes unauthorized access a criminal offense and requires U of U Health to report the unauthorized access to law enforcement for potential prosecution.

Signature of Visitor*

(type full name below)

Visitor's Home Address*

Reason for shadowing*

Please share any helpful information related to this request, including details regarding any current affiliation status with the University of Utah.

Send me a copy of my responses

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