OBSERVER APPLICATION PACKET CHECK LIST

ITEMS TO BE SUBMITTED

OBSERVER APPLICANTS:
Using the checklist, send only the items listed below to the Division
Coordinator
Dear Observer Applicant,

The Office of Academic Affairs has reorganized to centralize the processing of all student observers, in
doing so; we will be reducing the various applications to only one. This process is also an important tool
for us to track observers and to assure all applicants have an equal opportunity to observe. To facilitate
the processing and tracking of all student observers please complete materials provided in this packet,
when the packet is complete please forward to the division coordinator/administrative assistant.

PAG SUBMIT TO THE DIVISION COORDINATOR/ADMINISTRATIVE

E ASSISTANT
2 Observer Request Application
Refer
to page Addendum B Student, Observer, Non-Employee Health Clearance Form
3-4
5 Addendum C Observer Status (Signed & Dated)
6 Addendum D Confidentiality Stated (Signed & Dated)
10 Completed HIPAA Competency Test (Signed & Dated)
11 Addendum F Environment of Care Observation/Job Shadowing (Signed
& Dated)

Division Coordinators:
It will be your responsibility to keep all documents in your
electronic files for your records.

Feel free to contact us if you have any questions:

Martha Bustamante (323) 361-4541
Raquel Landeros (323) 361-2127

NOTE:
The CHLA picture ID cards are property of CHLA and must be returned on the final day
of the rotation to Martha Bustamante or Raquel Landeros, Duque Bldg., Door 1-294.

OBSERVATION Student Packet (revised 5/17/13rl) Page 1 of

10
 Applicant to send all materials to requested division/department coordinator.
OBSERVER REQUEST APPLICATION
Student / Research/ Graduate/Physician in Training (PIT)
(High School Student are not eligible)
Name of Observer: (First Name Middle Name Last Name) SS# /PASSPORT: 383-27-8227
Sheng Zhou
Email Address: shengz@usc.edu Cell Phone:
Current Address: 4225 Via Arbolada #519 City/State: Los Angeles Zip: 90042
Institution/School: Are you an Undergraduate School: Year level
medical student ?
University of Southern California MS1
Yes No

CHECK APPROPRIATE APPLYING STATUS:

0268 - Student 0273 Student /Physician 2064 Research 0265 Research Observer
/Physician Observer Observer (Over 30 days)
Observer (Over 30 days) (LESS than 30 days) Saban Research
Meds-490 & USC Keck School of Medicine
2 weeks maximum Dr. Geller-Undergrad Pre-Health
& Other affiliated programs
Start Date: Start Date: Start Date:
CCI #:
End Date: End Date: End Date: HIM #:
Note: End date cannot exceed PPD expiration date Start Date:
All students must provide documentation of influenza vaccine
End Date:
2029 Grad Student
(Over 30 days)
UCEDD &
other affiliated Programs
Start Date:
End Date:
Division Approval:
Name of Division: Attending Supervising Student: Supervising Attending Contact Info:
First Name - Last Name Phone:
Pager:
Email:
Division Coordinator: Email: Phone #:

CHLA Dept./Division Head or Designee Name

Name:______________________________________ Please check: Division Head Designee

Signature:X__________________________________ Date:_____________________________

Coordinators must email a PeopleSoft Application to

systemnotification@chla.usc.edu ; once the CHLA ID # is obtain it must be
included on the Observer Trainee Request Form
Research Observers who need KIDS access Coordinators must submit a RFUA to
the HELP DESK and include CCI #
HIM: KIDS access privileges only for 0265 Research Observer
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 ADDENDUM B

Clearance Process For

All Fellows, Rotating Residents, Students, Observers, etc
(Hereafter Referred to As Trainees)

In order to facilitate the processing of all trainees the following must be noted:

All trainees must be cleared by the Academic Affairs Office including Health Clearance
verified by a Program Coordinator before the Safety & Security/Parking Office will issue a
CHLA identification badge and parking card.

The following are the CHLA Health Screening/Clearance Requirements from Employee
Health Services and the L.A. County Department of Health

Every interim employee, student, intern, rotation resident, fellow, volunteer or persons
coming to observe a procedure must provide documentation of immunization for health
clearance prior to starting their employment, training rotation, or observation period at
CHLA. The following documents must be provided to the program coordinator at the
time clearance is being requested.

Please provide a copy of your documented immunization record containing:

1. Written document of two measles, mumps, rubella (MMR) vaccinations as a child

in persons born after 1950, or one MMR after the age of seventeen (17)
Or
Serologic (antibody titers) evidence of immunity to measles and rubella (German
Measles).
2. Serologic evidence of immunity to chicken pox (varicella) or verbal knowledge of
having the disease.
3. MUST BE CURRENT to the end date of the rotation: Written documentation and
report of TB skin test (Mantoux) or T-Spot / Quantiferon TB Test within the
previous twelve months
Or
In skin test positive persons, a written report of chest x-ray results taken within
the previous year.
4. Written documentation of one Tdap given as an adult
5. Written documentation of Hepatitis B Vaccine series
6. Written documentation of recent influenza vaccination (MUST BE UPDATED
during flu season during the months of October April)

Parking cards and identification will not be issued without Immunization

clearance. If the above is not carried out, the trainee will be considered
unauthorized to begin training at CHLA and is not permitted to be on campus.

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 ADDENDUM C

Academic Affairs MS #71

Ext. 12127 or 14541

Observer Status

I understand that my role as a visiting/shadowing student / undergraduate student/ Research Observer/ Required Scholarly

Program Student (RSP), USC UCEDD , Physician in Training (PIT) does not allow me to obtain a patients history, act as a

translator, examine patients, or interact with any patient being seen at CHLA or at any other sites affiliated with or contracted by

CHLA. As many staff and faculty members, residents, etc., may not be aware of my status, I will explain my role whenever

asked to interact with a patient. If I feel that undue pressure is being applied, I will report the situation to the Chief of Medical

Staff at CHLA. I will honor privacy and not remove or share any confidential patient information.

I also understand no grade or certificate of completion will be issued for this experience.

X_______________________________ X__________________________________
Signature Observer SignatureWitness (Supervising Physician)

________________________________ ____________________________________
Print-Observers Name (first-middle-last) Print-Witness Name (Supervising Physician)

________________________________ _____________________________________
Date Date

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 ADDENDUM D

CONFIDENTIALITY STATEMENT

In order to protect the confidentiality of patient care and hospital matters, Childrens Hospital Los Angeles
considers all information regarding its patients, their families, hospital employees and hospital business as
confidential. All board members, officers, employees, volunteers, residents/fellows, students, Medical Staff
members or practitioners with temporary privileges are required to adhere to this policy and not release or
disclose any information without appropriate written authorization. The hospital complies with all applicable
federal (HIPAA) and state law regarding the release of protected health information.

This policy includes the confidentiality of medical staff records and procedures, all patient information,
employee personnel files and information contained in the hospital computer systems.

Board members, officers, employees, volunteers, residents/fellows, students, Medical Staff members or
practitioners with temporary privileges are also asked to refrain from discussing any patient information or
hospital business in public areas, including corridors, elevators, the cafeteria, McDonalds, hospital lobbies or
waiting rooms.

ACKNOWLEDGEMENT:

I_________________________________________________, have read and agree to

PRINT NAME

comply with the Childrens Hospital Los Angeles, Confidentiality Policy. I understand that I am prohibited from
divulging any information regarding patients, their families, employees or matters related to hospital business
except as mandated by hospital policy and/or law.

Signature X _______________________________________________Date___________

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 ADDENDUM E

HIPAA
(HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT)

OBSERVATION/JOB SHADOWING

Primary Goals of the HIPAA Legislation

Assure health insurance portability

Reduce healthcare fraud and abuse
Simplify electronic administrative processes
Guarantee security and privacy of health information

HIPAA is the most sweeping legislation to affect healthcare since Medicare in 1965. Nearly everyone will
be affected: payors, employers, providers, clearinghouses, practice management system vendors, billing
agents, and service organizations. In regard to protecting patient information, security is defined as the
protection of information, data and systems from accidental or intentional access by unauthorized users.
Common threats to patient information security include talking about patients, using identifiable
information such as names, diagnosis, etc, in public areas.

Examples of Protected Health Information

Clinical information
Name and social security numbers
Names of relatives, family name, and employer
Health plan numbers and account numbers
Telephone numbers, fax numbers and emails
All dates related to the individual, i.e., birth, etc
Geographic subdivision smaller than state
Any information that can reasonably identify a patient

Penalties for Non-compliance with HIPAA Regulations

MONETARY PENALTY A. TERM OF B. OFFENSE

IMPRISONMENT
$100 N/A Single violation of a provision.
Up to $25000 N/A
Multiple violations of an identical requirement for
prohibition made during a calendar year.
Up to $50000 Up to 1 year Wrongful disclosure of individually identifiable
health information.

Up to $100000 Up to 5 years Wrongful disclosure of individually identifiable

health information committed under false
pretenses.
Up to $250000 Up to 10 years Wrongful disclosure of individually identifiable
health information committed under false pretenses
with intent to sell, transfer, or use for commercial
advantage, personal gain, or malicious harm.

Failure to implement transaction sets can result in fines of $225000 per year or more.
($25,000 per requirement, times nine transactions)

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Failure to implement privacy and security measures can result in imprisonment.

Patients Rights
Patients have the right to
- Look at and obtain a copy of their health information.
- Know how their health information has been used and to whom it has been disclosed.
- File a formal complaint if their privacy has been violated.
- Patient or parental consent must be obtained before a patients health information can be
released to family members.
- Protecting patient information includes electronic, written and verbal communication.

Notice of Privacy Practices

Covered Entities must provide a simple explanation of their privacy practices. Direct treatment providers
must make a good faith effort to obtain written acknowledgment of receipt of the notice of privacy
practices.

Minimum Necessary
Employees should use only the information minimally necessary to do their job.

Business Associates
Covered Entities may disclose PHI to business associates. They are required to have contracts that require
their business associates to observe certain privacy standards listed in the regulations.

PERSONAL REPRESENTATIVES (PARENTS)

HIPAA gives control of a minors PHI to the parent, guardian, or person acting in loco parentis with
certain exceptions.
HIPAA does not overturn state laws that give providers discretion to disclose PHI to parents or prohibit
the discloser of PHI to a parent.
Verification of the personal representatives identity is a critical overlap with physical security.

PRIVACY DOS

Immediately remove all patient health information from printers, fax machines and photocopiers.

Dispose of protected health information in the appropriate confidential bin.

When conducting a conversation regarding a patient, do so in a private place or speak quietly so you
cant be overheard.

Keep medical records and other documents containing personal health information out of public view.

When possible, close patient/examining room doors or draw curtains and speak softly when discussing
patients health information.

Treat other peoples confidential information as if it were your own.

Password protect your laptop computer and your personal digital assistant.

Report privacy violations in the hospital to the Privacy Officer, at extension 2302 so we can improve
our organizations privacy practices.

PRIVACY DONTS

Dont share confidential patient information with anyone who doesnt need to know in order to do his
or her job.

Dont share passwords on your computer.

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 Never access information about a patient unless you need it to do your job.

Dont walk away from open medical records, lab results, or computers, etc. Close records first and use
a bookmark, if necessary.

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 HIPAA Competency Test
OBSERVATION/JOB SHADOWING
Please circle correct answer:

1. Which of the following statements about confidentiality and protecting patient information are true?
A. Only authorized people are allowed to look at or use patient information
B. Any health information that can identify a person must be treated as confidential
C. Confidential information should be shared only with those who have the need to know
D. All of the above

2. In regards to protecting patient information, security is defined as:

A. The requirement that all patient information either be under lock and key or protected by security officers
B. The protection of information, data and systems from accidental or intentional access by unauthorized user
C. None of the above
D. All of the above

3. Which of the following standards require health care organizations to protect patient information?
A. Chain of Trust (COT)
B. Prospective Payment System
C. Health Insurance Portability and Accountability Act (HIPAA)
D. Outcomes Assessment Information Set (OASIS)

4. Organizations that violate patient privacy and security standards can suffer penalties such as:
A. Fines, possibly in the thousands of dollars
B. Imprisonment
C. Bad public relations
D. All of the above

5. Common threats to patient information security include:

A. Talking about patients, using identifiable information such as names, diagnosis, etc, in public areas
B. Not logging off the computer when finished
C. Maintaining patient listings and other information in full view of unauthorized people
D. All of the above

6. Patients have the right to:

A. Look at and obtain a copy of their health information
B. Know how their health information has been used and to whom it has been disclosed
C. File a formal complaint if their privacy has been violated
D. All of the above

7. Protected health information (PHI) is any information that can identify a patient
A. True
B. False

8. Talking about a patients condition or diagnosis, while in a public area, would be a violation of patient privacy
even if the patients name were not mentioned.
A. True
B. False

9. Patient or parental consent must be obtained before a patients health information can be released to family
members
A. True
B. False

10. Protecting patient information includes all forms of communicationelectronic, written and verbal.
A. True
B. False

Print Name:

Signature: Date:

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ADDENDUM F
ENVIRONMENT of CARE
OBSERVATION/JOB SHADOWING
Please keep this information, and sign and Fire/Life Safety
Rescue endangered patients. Close doors
return the enclosed statement indicating
Activate the alarm system
that you have read and understand your role Call Ext. 33 to report fire
in the safety, security, and environment of Contain the fire
care at Childrens Hospital Los Angeles. Extinguish the fire
Codes (Overhead Page) (Ext. 33) Know where the fire alarm & fire
Code Blue - Medical Team Emergency extinguishers are located
Code Green - Hazardous Spill Know that the hospital has a series of smoke
Code Yellow - Trauma Team compartments designed to prevent the
Code Red Fire spread of smoke and fire
Code Orange - Disaster Know that you may be needed to help
Code 10 Missing Patient transfer patients to another area
Code 12 Bomb Threat
Fire Extinguisher Use PASS
Code 13 Community Disturbance Pull the pin
Code 99 Hospital Lockdown Aim the hose/extinguisher
Dr./Mr. Strong Violent Behavior (Ext. 711) Squeeze the handle
Dr./Mr. Adam Strong Armed Individual (Ext. 711) Sweep from side to side
Identification Badges Evacuation Procedure
Your CHLA ID badge must be worn at Move horizontally beyond next fire/smoke door
all times when on the CHLA premises
Move vertically, two floors minimum or unit capable
Your ID badge must be worn on the upper
of receiving patient type
body with the photo and name facing outward
Meet at designated assembly area
If you loose your ID, you must report it
Account for all staff and patients
missing to Security (Ext. 2313) and the
Parking Office (Ext. 2214) Notify emergency operations center Ext. 2342
of status/missing persons
Visitor Badges Patient Priority those closest to danger, ambulatory,
All visitors to CHLA (whether parents, guardians families, vendors, those you can move yourself,
etc.) must have a visible ID badge those you need help to move
on their person
Visitor badges are as follows: Emergency Preparedness/Disaster Procedure
Yellow Badge visitors to inpatient care areas Code Orange will be announced overhead
Orange Badge visitors to outpatient clinics, All available hospital personnel report to the
labs, and the Emergency Dept. Command Center
Blue Badge Visitors to general/non-patient care areas
Medical Equipment Malfunction
Remove from service and sequester any
Wrong Badge or No Badge
medical equipment you suspect or know
All Medical Staff, House Staff, and pre- & post-
was involved in a patient incident
doctoral fellows and employees are responsible for: notify Risk Management immediately
Escorting visitors without badges to the Guest Assure that all equipment is reviewed by
Services Desk at the main entrance, or calling the Biomedical Dept. before it is used in
Security patient care
Asking if you can assist a visitor with the wrong
badge who is in the wrong area. Example: Visitor Utilities Failure
with a blue badge is seen in an inpatient care area. Know that the Hospitals emergency power
generators will start in less than 10 seconds.
Safety
Know that these power supply systems are
Know location of the Safety Manual
tested on a weekly basis
Know how to complete a Patient/Visitor You may be needed to assist patients whose
Event Report in the event something equipment has failed
unusual happens to you or your patient
Know process to follow in event of
Hazardous Materials/Waste utilization failure
Wear proper protective gear
Inquire regarding proper disposal
of chemicals
Require labels on all chemicals
that are used by you
Know where the MSDS for chemicals in your area are located

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 ENVIRONMENT of CARE
OBSERVATION/JOB SHADOWING

I have been oriented to the following information on the Role in Environment of Care:

Codes
Security Badges
Visitor Badges
Wrong Badge or No Badge
Safety Management
Hazardous Materials/Waste Management
Fire/Life Safety Management
Fire Extinguisher Use PASS
Evacuation Procedure
Emergency Preparedness Management
Medical Equipment Management
Utilities Management

Print Name:

Signature:

Date:

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