Receipt and Acknowledgement of the Spartanburg Regional Healthcare System’s

Regional Guide of Integrity

  • I have received my copy of the Regional Guide of Integrity (the “Guide”).
  • I understand that I am responsible for becoming familiar with its contents.
  • I acknowledge that I will comply with the Guide in the performance of my job.
  • I understand that ‘We’, as used in the Guide, refers to me, as an employee or agent of Spartanburg Regional Healthcare System.
  • If further clarification or explanation is required, I understand that I should consult with my supervisor of the Corporate Integrity Officer.
  • I UNDERSTAND THAT THE GUIDE DOES NOT CREATE A CONTRACT OF EMPLOYMENT AND THAT EMPLOYUEES OF SRHS ARE EMPLOYEE-AT-WILL WHO MAY QUIT AT ANY TIME FOR ANY REASON OR NO REASON.

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Date

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Student/Volunteer Name (Print)

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Student/Volunteer Signature

SPARTANBURG REGIONAL HEALTHCARE SYSTEM

Confidentiality Statement

NAME:______SCHOOL:______

PARENT/CHILD INFORMATION

I, the undersigned individual, do hereby state that I have applied to work as a student/volunteer at the Child Development Program (CDP) and by signing below I hereby acknowledge I have read this Confidentiality Statement and have agreed to comply with the terms and conditions as outlined herein. I understand my volunteering services with the CDP is contingent on my compliance with the following terms and conditions:

I understand that the CDP children and their parents have a right to privacy. Parents have a right to expect that details of their children’s development and behavior, medical history, family personal and financial affairs will be kept confidential by all CDP employees, students and volunteers. I understand it is not for a volunteer to decide what information a child/parent would not object to having disclosed, for what one person considers unimportant another may consider being highly sensitive or embarrassing.

I understand that all information (written, verbal, electronic, or printed) concerning a child’s medical condition or his/her experiences at the CDP, regardless of how such information is obtained, is confidential information. I agree not to refer to a child or family by name outside of the CDP setting and agree not to disclose or discuss such information with anyone other than those individuals directly involved in the care of the child or others with a legitimate reason to know the information.

CONFIDENTIAL BUSINESS INFORMATION

I acknowledge that certain business information of SRHS is considered confidential information. Such confidential information includes child enrollment, public relations and marketing information, family account information, training and operations material, memoranda and manuals, personnel records and manuals, cost information, and financial information concerning or relating to the business, accounts, families, employees, agents and affairs of SRHS. I acknowledge and agree that such information is the property of, and confidential to, SRHS, and further, that I will not publish or disclose, either directly or indirectly, any confidential information of SRHS.

PATIENT INFORMATION

While participating at the CDP, I may interact with medical staff. I understand that it is unacceptable for me to question any hospital employee about the condition of any patient or to discuss the condition of any patient with anyone.

ELECTRONIC/COMPUTER SYSTEMS

Electronic and computer systems include all computer-generated or stored data, voice mail, facsimile, and electronic mail services. The information transmitted by, received from, or stored in these systems is the property of Spartanburg Regional HealthCare System (“SRHS”). I hereby consent to SRHS monitoring my use of its electronic and computer systems at any time. I understand that such monitoring may include the printing and reading of all electronic mail entering, leaving or stored in these systems.

I understand that any violation of this Confidentiality Agreement may result in disciplinary action up to and including CDP’s refusal to allow me to continue serving as a volunteer and/or denial of participation in the hospital learning experiences. I understand that SRHS may have additional rights and remedies available to them in law or equity in cases of a disclosure of trade secrets or proprietary information.

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Signature Date

This is to certify that I have received orientation, was given the opportunity to ask questions, and understand the procedures in the following areas:

  1. General Policies and Procedures for students/volunteers
  2. Injury and Exposure Guidelines
  3. Quality of Care
  4. Confidentiality
  5. Corporate Integrity

Date: ______Signature: ______

Participant Pledge

  • I will be punctual and conscientious in the fulfillment of my duties and accept supervision graciously.
  • I will conduct myself with dignity, courtesy and consideration.
  • I will communicate in truthfulness at all times.
  • I will consider as confidential all information that I may hear directly or indirectly concerning a patient, physician or any member of personnel, and I will not seek information regarding a patient.
  • I will take any problems, criticism or suggestions to the Director of the Child Development Program or to an appropriate Supervisor.
  • I will endeavor to make my work of the highest quality.
  • I will uphold the tradition and standards of the Child Development Program and will interpret them to the community at large.

Date: ______Signature: ______

STUDENT/VOLUNTEER EMERGENCY INFORMATION

Should an emergency arise during your experience at the Child Development Program, we will need your permission to obtain treatment for you. Also, we may need emergency contact information. Please provide us with the following information:

Permission is hereby granted for ______to be treated in case of injury incurred while on duty as a practicum student, shadowing student or volunteer at the Ida Thompson Child Development Program.

______Date ______

Signature of Student

OR

Signature of Parents/Guardian, if under 18 years of age

Physician to be contacted in case of emergency:

Name ______Phone Number ______

Health Insurance Plan: ______ID # ______

If necessary to contact EMS, I prefer to be taken

to the following medical facility: ______

Emergency Contact Information:

1st - Name: ______

Home Phone: ______Work Phone: ______

Cell Phone: ______

2nd - Name: ______

Home Phone: ______Work Phone: ______

Cell Phone: ______

Special Health Conditions (i.e. diabetes, allergies) ______

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