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Before you are able to begin your Physician Assistant Pre-Clinical Shadowing/ Observational Experience, you will need to review the student handbook and complete the following: Observer Checklist Check when Complete Item to Complete / Obtain Faculty Attestation Statement for Shadowing Page 2 of this document Health Record Checklist Page 3 of this document Confidentiality and Security Agreement Page 4 of this document HIPAA Education Pages 9-10 in Handbook Infection Control Education Page 10 in Handbook Ideal Patient Experience (IPE) Pages 10-11 in Handbook Act 33 - PA Child Abuse History Clearance See Required Clearances Document Act 34 - PA Criminal Record Check See Required Clearances Document Act 73 - Fingerprint-Based Federal Criminal History Background Check See Required Clearances Document Return completed documents to: Office of Graduate Medical Education 1086 Franklin Street Johnstown, PA 15905 For questions, contact Graduate Medical Education at (814) 534-9892. Page | 1 FACULTY ATTESTATION STATEMENT FOR SHADOWING/OBSERVER I will be hosting , who will be shadowing/ observing from ____________________ to ____________________ (proposed dates). I understand that the above-named individual is not permitted to touch a patient, be alone with a patient, or write in a patient’s chart/record. Shadower & Faculty Member: ________________________________________ Faculty Member’s Signature __________________ Date ________________________________________ Phone or Pager Number ________________________________________ Shadower’s Signature Page | 2 __________________ Date Shadower/Observer HEALTH RECORD CHECKLIST INFORMATION FIRST LAST MIDDLE PROGRAM START DATE END DATE HEALTH REQUIREMENTS REQUIREMENT CHECK LIST Physical Exam (Within past 2 yrs) Date completed Criteria met: Yes_____ No_____ Intradermal PPD (TB testing) (Within 30 days) Step 1 completed Results Step 2 completed Results Positive/ Negative Positive/ Negative Rubeola (Qualitative) (Measles) Immunization status Qualitative Results Rubella (Qualitative) (German measles) Immunization status Qualitative Results Varicella (Qualitative) Immunization status Qualitative Results Diphtheria/Tetanus (Within past 10 years) Immunization date Criteria met: Yes_____ 7 Panel Urine Drug Screen Must be completed within 30 days of experience. Scheduled: Yes__________ No__________ Influenza Vaccine If on hospital campus at any time during flu season (10/1 – 3/31) must receive vaccine and provide documentation of such vaccine Page | 3 No_____ Page | 4
