Permission for Release of Vaccination Records

Permission for Release of Vaccination Records

JOB SHADOWS

Paperwork Check List Due February 27th

Please complete the below items and submit to Mrs. Duffy as one packet with this page as the cover sheet. A check next to the item means I have it on file and you do not need to resubmit.

• Permission for release of Vaccination records

• EXHIBIT “A” STATEMENT OF STUDENT RESPONSIBILITIES REGARDING AGENCY AND DISTRICT TRAINING PROGRAM

• EXHIBIT “B” STUDENT WAIVER OF LIABILITY

• EXHIBIT “C” STUDENT ACKNOWLEDGEMENT OF PATIENT CONFIDENTIALITY

• EXHIBIT “D” HEPATITIS B VACCINE WAIVER

(Exhibits A-D are required documents per our contract with the hospital)

• Dress Code Policy

• VCMC Nursing Department’s Statement on Confidentiality

• Proof of all necessary immunizations/tests

I have place a check next to the immunizations I currently have on file, so you do not need to include copies of these.

___MMR (full series)

___Varicella

___Tdap

___Influenza (needs to be within the last 6 months)

___Hepatitis B (if the entire series is not completed with a titer students can still be at risk, but will be allowed to attend as long as exhibit D form is submitted)

___Proof of PPD screen (needs to be within the last 3 months, so please complete in February)

September 30th, 2014

Dear Parents:

A significant part of the BioScience Academy experience is the real-life application of knowledge. Our plan is to place each student in several different professional environments this spring in order to observe the events that occur in an operating room, emergency department, public health clinic, clinical lab and many more. In order to meet the regulatory requirements of patient care facilities and for the student’s protection, each student must submit proof of the following immunizations as well as have a Tuberculosis skin test (PPD) to prove that they have not contracted the disease or been exposed to it.

Proof of immunization:

  • MMR (full series)
  • Varicella
  • Tdap
  • Influenza
  • Hepatitis B (if the entire series is not completed with a titer students can still be at risk, but will be allowed to attend as long as exhibit D form is submitted)
  • Proof of PPD screen (needs to be within the last 6 months)

Our health office provided records last year of some of these immunizations and I have kept all the files you previously submitted. However, it is possible that your child has not had some of the above vaccinations. Please make an appointment with your physician to do so. I am including a letter to your physician explaining why you will be requesting a PPD test in case they require this. A PPD test will require you to return to the office within 48 hours, so it’s important to plan accordingly. When you obtain these additional vaccines/screens, please send a copy of the clearance or immunization date with your child to me.

Please sign the accompanying paperwork and have your child bring them to Mrs. Duffy by the indicated date on the page titled “Paperwork Checklist”. We will begin job shadows the second week in April and need to have this paperwork in place before then. Without this clearance, students will not be able to shadow at VCMC. They can be placed at other locations – but not in the hospital. If you have any questions, do not hesitate to contact me.

More information regarding the job shadow check-out procedure will follow in March.

Thank you – Darcy Duffy, BioScience Academy Director

Permission for release of Vaccination records

I grant my permission to release my child’s immunization records to the school nurse for the purpose of submission to the Ventura County Medical Center in order to meet the infection control requirements.

Student Name:

Parent Name:

Parent Signature:

Date:

EXHIBIT “A”

STATEMENT OF STUDENT RESPONSIBILITIES REGARDING AGENCY AND DISTRICT TRAINING PROGRAM

  1. Provide proof of immunization or documented immunity against MMR, Varicella, Tdap, influenza, Hepatitis Band proof of PPD screen. Hepatitis B immunization is strongly advised. If a student has not completed the full series they shall sign a waiver of liability for acquiring hepatitis B. Note: The cost of all required vaccinations will be the sole responsibility of the student or his/her parent or guardian.
  1. Conform to all applicable AGENCY policies, procedures, and regulations, and such other requirements and restrictions as may be mutually specified and agreed upon by the designated representative of AGENCY and DISTRICT.
  1. Follow additional Rules and Regulation which a student must be noticed of and/or expected to comply with regarding:

Student Signature: ______Date: ______

Student Name: ______

Parent Name: ______

Parent Signature: ______

EXHIBIT “B”

STUDENT WAIVER OF LIABILITY

1.In consideration of the educational opportunity afforded to me by AGENCY, I hereby waive any claim for damages against AGENCY, its employees, and/or agents alleged to have resulted from any tortuous acts or omissions of AGENCY, its employees, and/or agents.

Student Signature: ______Date: ______

Student Name: ______

Parent Signature: ______

Parent Name: ______

2.In consideration of the educational opportunity afforded to me by DISTRICT, I hereby waive any claim for damages against DISTRICT, its employees and/or agents alleged to have resulted from any tortuous acts or omissions of DISTRICT, its employees and/or agents.

Student Signature: ______Date: ______

Student Name: ______

Parent Signature: ______

Parent Name: ______

EXHIBIT “C”

STUDENT ACKNOWLEDGEMENT OF PATIENT CONFIDENTIALITY

The undersigned hereby recognizes that medical records, patient care information, personnel information, reports to regulatory agencies, and conversations between or among any health care professionals regarding patient matters are considered confidential, and should be treated with utmost confidentiality. If it is determined that a breach of confidentiality has occurred as a result of my actions, I can be liable for damages that result from such a breach, and possible termination from the Program.

Signed: ______Date: ______

Print Name: ______

Parent Signature: ______

Parent Name: ______

EXHIBIT “D”

HEPATITIS B VACCINE DECLINATION (WAIVER)

I HAVE BEEN INFORMED AND UNDERSTAND THAT DUE TO MY PARTICIPATION IN THIS COURSE EXPOSURE TO BLOOD AND/OR OTHER POTENTIALLY INFECTIOUS MATERIALS, THAT I MAY BE AT RISK OF ACQUIRING HEPATITIS B VIRUS (HBV) INFECTION. I HAVE BEEN ADVISED, AND GIVEN THE OPPORTUNITY TO BE VACCINATED FOR A FEE WITH HEPATITIS B VACCINATION.

STUDENTS MUST CHECK ONE OF THE BOXES:

I DECLINE THE HEPATITIS B VACCINATION, AND UNDERSTAND THAT BY DECLINING THIS VACCINE, I CONTINUE TO BE AT RISK OF ACQUIRING HEPATITIS B, A SERIOUS DISEASE.

I HAVE FULLY COMPLETED THE HEPATITIS B VACCINATION SERIES, AND THEREFORE I DECLINE THIS OPPORTUNITY TO BE VACCINATED WITH THE HEPATITIS B VACCINATION.

I HAVE BEGUN THE HEPATITIS B VACCINATION SERIES AND UNDERSTAND THAT I CONTINUE TO BE AT RISK OF ACQUIRING HEPATITIS B, A SERIOUS DISEASE, AND WILL CONTINUE TO COMPLETE THE ENTIRE SERIES OF VACCINATION.

Print Name: ______Date: ______

Signature: ______

Parent Signature: ______

Parent Name: ______

Dress Code Policy

The image of a healthcare professional is well groomed and dressed appropriately for their position.

For your Job Shadow or Internship, please wear your scrubs or your lab coat.

The following are basic standards:

 Jeans, tank tops, tube tops, t-shirts, sweats, shorts, miniskirts and sundresses are not accepted as appropriate work or business attire.

 Shoes should be closed toed. They should be appropriate for the job and have safe soles and heels.

 Socks or hosiery are to be worn at all times.

 Moderation must be exercised in the use of makeup, jewelry or cologne. If you are assigned to direct patient contact, do not wear perfumes or colognes.

 Do not show up with body piercing, visible tattoos or clothing that embodies or visibly displays “gang” symbolism.

 Hair must be neat and clean. Beards, mustaches and sideburns must be neatly trimmed.

I have read the above dress code summary of standards and agree to follow the basic standards as outlined above.

______

Student SignatureDate

______

Parent SignatureDate

VCMC Nursing Department’s Statement on Confidentiality

Ventura County Medical Center regards the professional principles of patient privacy and confidentiality of the medical record (electronic or paper) to have the highest priority.

Every patient entering our facility has the right to expect absolute confidentiality concerning their medical record, and medical information.

There are five acceptable reasons to access a patient’s medical record, electronic or paper.

1. As a member of the team providing the patient’s care: with restrictions to information that is necessary to perform assigned job duties.

2. As part of a peer review or chart auditing process: i.e. chart completeness, appropriateness of care, analysis of adverse outcomes, chart accuracy, etc.

3. As part of the billing or insurance functions.

4. As part of any legal, regulatory, or litigation matters.

5. As part of a student nursing assignment.

Any other access to the medical record is with patient permission only, following defined hospital policy. Permission to access the medical record of any patient is required by any person(s) not meeting the above criteria. The permission should be in writing.

Ventura County Medical Center has zero tolerance for unauthorized entry into the medical record and will deal with breaches accordingly.

Print Name: ______Date: ______

Signature: ______

Parent Signature: ______

Parent Name: ______

September 30th, 2014

To Whom it May Concern

This student is going to be participating in a Job Shadow Program in the Ventura County Medical Center as a requirement of the BioScience Academy at Foothill Technology High School. In order to participate in this program, this student must have a PPD screen. This student will be shadowing physicians and nurses in multiple locations including the operating room and emergency department as well as exam rooms. Thank you for your assistance with this matter.

Darcy Duffy

BioScience Academy Director

Foothill Technology High School