The Behavioral Health Center is a free-standing psychiatric hospital that is part of Eastern Idaho Regional Medical Center with:
- Passing grade in Psych 342 Abnormal Psychology
- Completion of the internship application
- Completion of the Confidentiality and Security Agreement
- Completion of the Student Health Questionnaire
- Completion of the Educational Experience Checklist
- A recent TB (PPD) test
- An interview with Dr. Richard Cluff
Requirements: This internship will require a minimal commitment of 2 credit hours which equate to 100 hours of service.
Name: ____________________________ Major: ____________________________
Year in school: Freshman _____ Sophomore _____ Junior ______ Senior ______
GPA: _____ Phone Number: ________________________ Email: ______________________
Do you have personal transportation: Yes ______ No ________
If no, what arrangements have you made to guarantee your ability to meet your internship obligations? ______________________________________________________________________________
Available Blocks of time if selected as an intern:_______________________________________
Have you completed the Abnormal Psychology Course: Yes_________ No_________
Coursework related to this placement: _______________________________________________
Previous positions of responsibility/leadership: _______________________________________
Other information that may be useful to us in making a determination of your "fit" with this
Internship opportunity/placement: __________________________________________________
Upon completion make an appointment to meet with Dr. Cluff for a brief interview and bring this application.
The following checklist must be completed prior to the first clinical experience at EIRMC.
A completed checklist must be submitted yearly for all on-site faculty and students. All signed and completed checklists are to be returned to the EIRMC Education Department.
FACULTY NAME______________________________________________ EDUCATIONAL INSTITUTION___________________________________ PROGRAM________________________ DATE_____________________
I agree that I have complied with all provisions in the EIRMC Student /Faculty Policy (HR Policy 900.39). These include:
1. ______ Student Health Questionnaire
2. ______ Signed copy of "Confidentiality & Security Agreement"
3. ______ Review of "Student Orientation Booklet"
All of the above documents and supporting verification are to be retained and kept on file by the educational institution for each student.
I understand that the facility or business entity (the "Company") in which or for whom I work, volunteer or provide services, or with whom the entity (e.g., physician practice) for which I work has a relationship (contractual or otherwise) involving the exchange of health information (the "Company"), has a legal and ethical responsibility to safeguard the privacy of all patients and to protect the confidentiality of their patients' health information. Additionally, the Company must assure the confidentiality of its human resources, payroll, fiscal, research, internal reporting, strategic planning, communications, computer systems and management information (collectively, with patient identifiable health information, "Confidential Information").
The following statements apply to physicians using Company systems containing patient identifiable health information (e.g. CPCS/Meditech):
Signing this document, I acknowledge that I have read this Agreement and I agree to comply with all the terms and conditions stated above.
Employee/Consultant/Vendor/Office Staff/Physician Signature
Facility Name and COID
Employee/Consultant/Vendor/Office Staff/Physician Printed Name
Business Entity Name
Nov. 1, 2001 Attachment to IS.SEC.005
I. STUDENT/ FACULTY ON-SITE HEALTH QUESTIONNAIRE
NAME: ___________________________________ BIRTHDATE: ____________
EDUCATIONAL INSTITUTION: ______________________________________
Please answer the following questions and attach appropriate documentation.
1. Have you ever had Chicken Pox (Varicella)? Yes ____ No ____
If "NO": Attach a copy of Varicella titre results or proof of Varicella Vaccination.
2. Were you born in or after 1957? Yes ____ No ____
If "YES": Attach a copy of proof of two Measles, Mumps, and Rubella
(MMR) Vaccinations or attach a copy of results of Rubella and Rubeola
3. Have you ever had a positive reaction to a TB (PPD) skin test?
Yes ____ No ____
If "YES": Attach copy of results of chest x-ray taken within the last 12
If "NO": Attach copy of results of recent TB Skin Test (PPD).
AN ANNUAL TB SKIN TEST IS REQUIRED.
SIGNED: ________________________________ DATE: _________________
Completed questionnaire and appropriate supporting documentation to be retained and kept on file at the educational institution for each student.
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