Health Requirements Packet - University Of South Carolina Upstate

CONFIDENTIALITY AGREEMENTSPARTANBURG REGIONAL HEALTHCARE SYSTEMNAME: SCHOOL:PATIENT INFORMATIONPatients have a right to privacy. They have a right to expect that details of their condition, treatment, andmedical history. Personal and financial affairs will be kept confidential by all hospital employees and agents. Itis not for an employee or agent to decide what information a patient would not object to having disclosed, forwhat one person considers another may consider being unimportant highly sensitive or embarrassing.I understand that all information (written, verbal, electronic, or printed) concerning a patient’s medicalcondition or relating to or referring to a patient’s medical records, regardless of how such information isobtained, is confidential medical information. I agree not to disclose or discuss such information with anyoneother than those individuals directly involved in the care of the patient or others with a legitimate businessreason to know the information.CONFIDENTIAL BUSINESS INFORMATIONI acknowledge that certain business information of SRHS is considered confidential information. Suchconfidential information includes patient or vendor lists, public relations and marketing information, patientaccount information, training and operations material, memoranda and manuals, personnel records and manuals,cost information, and financial information concerning or relating to the business, accounts, patients,employees, agents and affairs of SRHS. I acknowledge and agree that such information is the property of, andconfidential to, SRHS, and further, that I will not publish or disclose, either directly or indirectly, anyconfidential information of SRHS.ELECTRONIC/COMPUTER SYSTEMSElectronic and computer systems include all computer-generated or stored data, voice mail, facsimile, andelectronic mail services. The information transmitted by; received from, or stored in these systems is theproperty of Spartanburg Regional HealthCare System (“SRHS”). I hereby consent to SRHS monitoring my useof its electronic and computer systems at any time. I understand that such monitoring may include the printingand reading of all electronic mail entering, leaving, or stored in these systems.I understand that electronic and computer systems are to be used solely for SRHS purposes and agree not tocopy, modify or otherwise access the software without the appropriate written authorization. I further agree notto circumvent my password or security level. I acknowledge that software is protected by a variety of licensingagreements and laws and that any misuse of the software may subject me to legal liability as well as disciplinaryaction up to and including termination from hospital learning experiences.I understand that any violation of this Confidentiality Agreement may result in disciplinary action, up to andincluding termination from hospital learning experiences. I understand that SRHS may have additional rightsand remedies available to them in law or equity in cases of a disclosure of trade secrets or proprietaryinformation.Signature3Revised 05/2014Date

EXHIBIT AWAIVER AND RELEASEThis Waiver and Release is entered into and signed as of this day of ,20 , by , a student of 86& 8SVWDWH (“College”), located in6SDUWDQEXUJ 6RXWK &DUROLQD (“Student”), to and in favor of Spartanburg Regional Health ServicesDistrict, Inc., a public hospital corporation and political subdivision of the State of South Carolina(“SRHSD”). In the event that Student is under the age of eighteen (18), then this Waiver and Release ismade with the consent and joinder of 1 as parent or legal guardianof Student (“Parent”).WHEREAS, Student has been accepted for enrollment in an internship through College to take placeon the premises of SRHSD (“Internship”), conditioned upon execution and delivery of this Waiver and Release;andWHEREAS, Student and/or Parent are willing to execute and deliver this Waiver and Release in orderto induce SRHSD to allow Student to participate in the Internship;NOW, THEREFORE, for and in consideration of the mutual promises contained herein, and for theopportunity to participate in the Internship, Student and/or Parent hereby agree as follows:1.Medical Condition and Coverage. Student has consulted with a physician as to his personalmedical condition, and represents that he suffers from no health-related issues which preclude orrestrict participation in the Internship. Student is further aware of his medical condition and needs,and has arranged for adequate medical insurance to meet any and all needs for payment of hospitalcosts, and that Student and/or Parent assumes all risk and responsibility therefore. In the event thatStudent’s medical condition or needs change during the course of the Internship in any way thatcould affect his participation in the Internship, then Student and/or Parent agree to notify Collegeand SRHSD of such change.2.Conduct. Student acknowledges that SRHSD may suspend and immediately remove from thepremises and Internship any Student when their performance is unacceptable in reference to theFacility’s standards of behavior or their conduct is disruptive or detrimental to the Facility or itspatients, within the sole judgment of SRHSD.3.Assumption of Risk. Knowing the dangers, hazards and risks associated with participation in theInternship, and in consideration of being allowed to participate, Student and/or Parent, on behalf ofStudent, his heirs, assigns, guardians, personal representative and all other persons claiming by orthrough him, voluntarily agrees to assume all risks and responsibility surrounding participation inthe Internship, including transportation, and releases and forever discharges, holds harmless andagrees to defend and indemnify, SRHSD, its board, officers, agents, insurers, affiliates andemployees from and against any and all damages or liabilities arising in any way out of or related tolosses, damages, or injuries, including death, suffered by Student while participating in, or in transitto or from, the Internship, whether based upon tort (including without limitation premises liability),contract, or otherwise.4.Release of Records. Student understands and acknowledges that, by providing the informationrequested below, he is consenting to College and or SRHSD using such information in order toconduct a criminal records check, drug test health screening, and hereby grants permission for suchchecks, tests and/or screens to be conducted. Student further understands and acknowledges that heis to advise College of any arrests or criminal charges subsequent to completion of this form, and4Revised 05/2014

that failure to do so may result in dismissal from the internship program. Student grants permissionto College and SRHSD to receive and exchange the criminal records check, drug test results andhealth screens if shared for the limited purpose of determining Student’s suitability to participate inthe internship.5.Nonemployment. Student acknowledges that the Internship constitutes a clinical learningexperience for which the student will receive no monetary or other compensation from the Facility,and that the Internship does not create an employer/employee relationship as between the studentand the Facility.6.Miscellaneous Provisions. In signing this Waiver and Release, Student/Parent acknowledge thatthey are fully aware of the content of this waiver, and are executing and delivery this Waiver andRelease freely and voluntarily, only after having fully read and understood the contents hereof.Student states that he is years old, and if over the age of eighteen (18), fullycompetent to sign this Waiver and Release. This Waiver and Release shall be construed inaccordance with the internal, substantive, laws of the State of South Carolina, without effect to anychoice of laws provisions that would result in the application of the laws of any other state. TheCourt of Common Pleas for Spartanburg County, South Carolina, shall be the exclusive forum forany suits filed under or incidental to this Waiver and Release or the Internship, and all partieshereby consent to jurisdiction therein. This Waiver and Release shall be severable, such that in theevent that any court of competent jurisdiction holds any term to be illegal or unenforceable, then thevalidity of the remaining portions of such provision and of this Waiver and Release shall not beaffected thereby.IN WITNESS WHEREOF, the undersigned party (and if under the age of eighteen, parties) has executedthis Waiver and Release as of the date first written above.WitnessStudent3ULQW QDPHStudent Name:6LJQDWXUHStudent Date of BirthStudent Current AddressStudent GenderStudent 9,3 ID5Revised 05/2014

UNIVERSITY OF SOUTH CAROLINA UPSTATEMARY BLACK SCHOOL OF NURSINGBACCALAUREATE NURSING PROGRAMCONFIDENTIALITY AGREEMENTPATIENT INFORMATIONPatients have a right to privacy. They have a right to expect that details of their condition, treatment, medical history,personal and financial affairs will be kept confidential by all hospital employees and agents. It is not for an employee oragent to decide what information a patient would not object to having disclosed, for what one person considers anothermay consider being unimportant highly sensitive or embarrassing.I understand that all information (written, verbal, electronic, or printed) concerning a patient’s medical condition orrelating to or referring to a patient’s medical records, regardless of how such information is obtained, is confidentialmedical information. I agree not to disclose or discuss such information with anyone other than those individuals directlyinvolved in the care of the patient or others with a legitimate business reason to know the information.CONFIDENTIAL BUSINESS INFORMATIONI acknowledge that certain business information of any health care provider is considered confidential information. Suchconfidential information includes patient or vendor lists, public relations and marketing information, patient accountinformation, training and operations material, memoranda and manuals, personnel records and manuals, cost information,and financial information concerning or relating to the business, accounts, patients, employees, agents and affairs of anyhealth care provider. I acknowledge and agree that such information is the property of, and confidential to, the provider,and further, that I will not publish or disclose, either directly or indirectly, any confidential information of the health careprovider.ELECTRONIC/COMPUTER SYSTEMSElectronic and computer systems include all computer-generated or stored data, voice mail, facsimile, and electronic mailservices. The information transmitted by; received from, or stored in these systems is the property of the health careprovider. I hereby consent to the health care agency 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 inthese systems.I understand that electronic and computer systems are to be used solely for the health care agency’s purposes and agreenot to copy, modify or otherwise access the software without the appropriate written authorization. I further agree not tocircumvent my password or security level. I acknowledge that software is protected by a variety of licensing agreementsand laws and that any misuse of the software may subject me to legal liability as well as disciplinary action up to andincluding termination from hospital learning experiences.I understand that any violation of this Confidentiality Agreement may result in disciplinary action, up to and includingtermination from hospital learning experiences. I understand that the health care agency may have additional rights andremedies available to them in law or equity in cases of a disclosure of trade secrets or proprietary information.Print NameSignatureDate6

UNIVERSITY OF SOUTH CAROLINA UPSTATEMARY BLACK SCHOOL OF NURSINGBACCALAUREATE NURSING PROGRAMCONSENT TO RELEASE INFORMATIONI authorize the University of South Carolina Upstate, Mary Black School of Nursing to release such academic and otherinformation from my educational record to furnish statements of reference requested by prospectiveemployers and/or other educational institutions to which I have applied.HONOR PLEDGEI do solemnly pledge on my honor as an USC UPSTATE nursing student to faithfully uphold the standards set forth in theUniversity's Code of Student Conduct. I will abide by all University rules, regulations and policies governing my conduct.I will refrain from any acts of academic dishonesty both in the classroom and clinical settings, and in my work on/out ofclass/clinical assignments.As a USC UPSTATE student, I am always on my honor not to lie, plagiarize, cheat or steal and to report any student whoviolates this pledge.Print NameStudent SignatureDate7

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DHEC Confidentiality AgreementI understand that:(a) the South Carolina Department of Health and Environmental Control (DHEC) has a legal and ethicalresponsibility to protect confidential information given or made available to DHEC in administration ofthe agency’s programs and services;(b) during the course of my employment, volunteer services, contract performance, or other agencyrelationship with DHEC, I may have access to confidential information in many forms, oral, written, andelectronic;(c) my compliance with this confidentiality agreement is an essential condition of my employment,volunteer services, or contractual or other agency relationship with DHEC; and(d) violation of this Agreement may result in termination of my volunteer, contractual, and/or workrelationship with DHEC or my employer and may be grounds for disciplinary action, fines, penalties,imprisonment, or civil suit to be brought against me.Confidential information is information known or maintained in any form, whether oral, written, orelectronic, whether recorded or not, consisting of protected health information, other health information,personal information, personal identifying information, confidential business information, and otherinformation required by law to be treated as confidential, designated as confidential by the Department, orknown or believed by me to be claimed as confidential or entitled to confidential treatment. Examples ofconfidential information include but are not limited to: personal information of job applicants, DHECemployees, DHEC clients, or members of the public, such as an individual's photograph or digitizedimage, social security number, date of birth, driver's identification number, name, home address, hometelephone number, medical or disability information, physical or mental health, health care, payment forhealth care, education level, financial status, bank account numbers, account or identification numbersissued or used by any federal or state governmental agency or private financial institution, employmenthistory, height, weight, race, other physical details, signature, biometric identifiers, credit records orreports, trade secrets, and confidential business information.By signing this agreement, I understand and agree that:(1) I will not disclose confidential information unless the disclosure complies with DHEC policies and isrequired to perform my responsibilities.(2) I will not disclose confidential information without written authorization from affected persons orparties, except as required by law or, if an employee, as required to perform agency responsibilities.(3) I will not access or view any confidential information other than what is required to do my job.(4) If I have any questions about whether I need access to certain information, or whether certaininformation should be disclosed, I will immediately ask my supervisor for clarification.(5) I will immediately report any unauthorized disclosure of confidential information to the DHECPrivacy Officer and my supervisor or to the DHEC Procurement Officer, if I am an employee of acontractor.(6) I will immediately report any request I receive for confidential information, including a subpoena,litigation discovery request, court order, or Freedom of Information Act request, to my supervisor, or theDHEC 321 Rev 4//20139Page 1 of 2

DHEC Confidentiality AgreementDHEC Procurement Officer, if I am an employee of a contractor, and the DHEC Office of GeneralCounsel.(7) I will not discuss any confidential information obtained in the course of my relationship with DHECwith any person or in any location outside of my area of responsibility in DHEC, except as otherwiserequired or permitted by law.(8) I will not make any unauthorized copy or disclosure of confidential information, or remove or transferthis information to any unauthorized location.(9) My obligations under this Agreement regarding confidential information will continue aftertermination of my employment/volunteer assignment/contract affiliation with DHEC.THIS CONFIDENTIALITY AGREEMENT DOES NOT CREATE AN EMPLOYMENTCONTRACT BETWEEN ME AND THE DEPARTMENT.I have read the above Agreement and agree to comply with all its terms.Print name:Signature: Date:Witness: Date:Work Location: 1 DHEC 321 Rev 4//201310Page 2 of 2

UNIVERSITY OF SOUTH CAROLINA UPSTATEMARY BLACK SCHOOL OF NURSINGBACCALAUREATE NURSING PROGRAMCONSENT/WAIVER FOR HEPATITIS B VACCINEPlease sign the appropriate area (one section only):(Print Name) have been immunized against Hepatitis B.1. I,Dates of Immunizations:(All three HepB shot dates)1.2.3.TITER Date:ORTiter Results: Immune Not ImmunePrint Name:Signature:Date:OR2. I, (Print Name), have begun the Hep B vaccine series. Iwill complete the series of injections in the time frame required.Dates of Immunizations:1.2.3.Print Name:Signature:Da

Nursing course failure from USC Upstate . or any other school, it will count as the one allowable failure within the Mary Black School of Nursing program. o I will regularly check my USC Upstate email address and Blackboard for announcements regarding the Mary Black School of Nursing baccalaureate program including, but not limited to