RIVERSIDE MEDICAL CENTER DEPARTMENT OF EDUCATION

KAISER PERMANENTE RIVERSIDE DEPARTMENT OF EDUCATION

MEDICAL STUDENTS - 2014 STUDENT INFORMATION

Name: _________________________________________ Telephone #: ________________________

Student Email: _________________________________________________________________________

Affiliated School: _______________________ What Program are you in? __________________________

Instructor/Coordinator: _______________________________ Cell Phone/Pager: _____________________

Instructor/Coordinator email: _________________________ Start Date: _________ End Date: __________

PRECEPTED STUDENTS ONLY

Name of Preceptor/Mentor: _________________________ Dept/Module: ________________ Ext: _______

Hours required to complete: ___________ Start Date: _____________ End Date: ______________

REQUIRED DOCUMENTATION

DOCUMENTS EDUCATION USE ONLY

Contract with School Yes No Rotation Application Information Form & CV State Drivers License provide CLEAR copy

BLS(required)/ACLS/PALS/NRP provide copy of both sides with signature

Professional Liability Insurance

Letter of Good Standing signed by Dean

HEALTH SCREENING (Immunizations) Letter from Student Health that you have had the following: MMR (Measles, Mumps, Rubella)

Date:

VARICELLA (Chicken Pox) Titer Date: HEP B Series/Titer Date: TB (PPD) w/in 1 Year* – Date: *see explanation of required immunizations

CHEST X-RAY– Date:

Influenza (flu) Vaccine w/in 1 Year Date:

Tdap (Recommended) Date:

KAISER FORMS

2014 Compliance Training – Online Annual Compliance – Once I have all the completed forms. I will order your

NUID & request a KPLEARN account. Once the KPLEARN account is activated, you may log on using your NUID & complete online training. Please print Certificate of Completion and email or fax to me.

Alcohol and Drug Free Work Environment Confidentiality Agreement – 3 Pages

Child Abuse Reporting Requirements

Elder and Dependent Adult Care Report Requirements EMATLA Hand washing Policy

Infection Control Test

Spotlight on Safety (SOS) Test

Badge INELIGIBILITY FOR WORKERS’ COMPENSATION I understand that I am not eligible for Workers’ Compensation claims through Kaiser Permanente Hospital, Riverside Medical Center, or Southern California Permanente Medical Group for any injuries sustained during the course of my Preceptorship, Internship, or Clinical Rotation. _____________________________________________ __________________________ Student Signature Date _________________________________________________ _________________________ Kaiser Permanente Graduate Medical Education Dept. Date

** Completion of this application packet does not guarantee you a placement at Kaiser Permanente.

Southern California Medical Student Rotation Application

Specialty:

Location:

Name: (please print)

Address: (please print) CITY STATE ZIP

Phone: Cell Phone:

Email:

Medical School: Year of Graduation:

ROTATION TIME period:

1st Choice From To (mo/day/yr) (mo/day/yr)

2nd Choice From To (mo/day/yr) (mo/day/yr)

Honors Projects:

Future Plans:

(Applicant Signature)

LETTER OF GOOD STANDING FROM YOUR STUDENT AFFAIRS OR DEAN’S OFFICE MUST BE ENCLOSED

FOR PRECEPTOR’S USE ONLY

Approved:________________________________________________ Date:_________________

KAISER PERMANENTE.Print NameEmp # Dept:

Tetanus, Diphtheria & Pertussis (Tdap)Declination

I have had the opportunity to review the latest CDC educational material (VaccineInformation Sheet Tdap 11/18/08) and ask questions regarding: 1) Tetanus, diphtheria &pertussis and their risks to health care personnel, and 2) the potential risks and benefits ofthe Tetanus, diphtheria & pertussis (Tdap) vaccine.

Please select ONE of the following:

I have received the Tdap vaccine on (approx. date).

I have received the Td vaccine on (approx. date)

I have elected NOT to receive the Tdap vaccine at this time. Iunderstand that I may elect to receive the Tdap vaccine at a later time. If so, I willcontact Employee Health (ext XXXX) to make arrangements for the vaccine.

I understand that due to my occupational exposure to aerosol transmissible diseases,I may be at risk of acquiring an infection with pertussis. I have been given theopportunity to be vaccinated against this disease or pathogen with Tdap at nocharge to me. However, I decline the Tdap vaccination at this time. I understandthat by declining the Tdap vaccine, I continue to be at risk of acquiring, a seriousdisease. If in the future I continue to have occupational exposure to aerosoltransmissible diseases and want to be vaccinated, I can receive the Tdapvaccination at no charge to me.

Signature Date

VISITING RESIDENT/MEDICAL STUDENT REGISTRATION MEDICAL STUDENT DEMOGRAPHIC INFORMATION

Legal First Name: Middle Initial: Legal Last Name: Maiden/Other Name:

Gender:

Male Female SSN: Date of Birth: Current PG Year:

Home Address: City, State, Zip:

Email address: Cell Phone: Pager:

Resident Fellow Medical Student Other (please specify)

Current Program: Current Institution:

Program Start Date: Anticipated Graduation Date:

Rotation: Start Date: End Date:

CA Medical License: Expires: DEA License: Expires:

ECFMG License: Issued: National Provider Identifier:

MEDICAL SCHOOL INFORMATION Medical School Name:

City/State/Country: Graduation Date: Degree:

POSTGRADUATE TRAINING

List all years of postgraduate training, employment, and time off since receiving a medical degree. Please account for every academic year since medical school graduation, with no gaps.

FROM (mm/dd/yyyy)

TO (mm/dd/yyyy)

SPECIALITY (PGY) / OTHER ACTIVITY INSTITUTION/LOCATION

Signature Date

SCAL

ALCOHOL AND DRUG-FREE WORKPLACE--EMPLOYEE ACKNOWLEDGEMENT

NAME: Please print (Use your complete legal name as it appears on your paycheck)

LAST NAME:

FIRST NAME:

MIDDLE INITIAL:

I.D. NUMBER: (As it appears on your paycheck)

NUID #, if known:

WORK PHONE NUMBER: (Tieline and outside)

Tieline:

Outside:

MANAGER’S NAME: (Please print)

LAST NAME:

FIRST NAME:

MANAGER’S WORK PHONE NUMBER:

Content Delivery Method Read/Acknowledge

LOCATION/FACILITY NAME: DEPARTMENT:

I understand that, as a provider of health care, Kaiser Permanente recognizes that chemical dependency is a chronic disease that can have tragic consequences for individuals, families, and the workplace.

As a condition of employment, all employees are expected abide by the organization’s policy which prohibits the use and/or abuse of drugs, including alcohol, in the workplace.

By my signature below, I acknowledge, understand, accept, and agree to comply with this policy. I also understand that failure to comply with these policies may result in disciplinary action up to and including termination.

ALCOHOL AND DRUG-FREE WORKPLACE ATTESTATION I have received a copy of SCAL HR Policy 5.03: Alcohol and Drugs.I have read, understood, and familiarized myself with this policy, and understand that Kaiser Permanente iscommitted to providing a drug-free workplace.I understand that it is my responsibility to comply with this policy, and that this policy applies to me.I agree to abide by the terms of the policy, as a condition of employment.I understand that violations of this policy will subject me to disciplinary action, up to and including discharge.If I have any questions about this policy, I will seek clarification from my manager or a KP HR Consultant.I understand that, in acknowledgment that chemical dependency is a chronic disease and that rehabilitativetreatment is available, KP supports the use of such treatment, and will provide it when conditions andcircumstances warrant.I understand that, if I am experiencing alcohol or drug dependency, I am urged by the organization to makeuse of KP’s confidential Employee Assistance Program, and/or such disability plans, rehabilitation programs,and health coverage plans as are appropriate.

_______________________________________________________________________ Signature Date Completed

EMTALA ATTESTATION

I read and understand the EMTALA requirements. I know my role in ensuring adherence to the requirements including escalation of concerns to my department’s leadership as needed.

NAME TITLE DATE

EMTALA Requirements;jk;8.11.06: SDSA origination

H:/GME/Orientation/2007 Orientation/Hiring Paperwork/Hand Decontamination Policy Form.doc Revised 2-2007

HAND DECONTAMINATION POLICY REVIEW AND DISTRIBUTION DOCUMENTATION

Date: ______________________

I have been informed of the Kaiser Permanente Hand Decontamination Policy and the requirement to eliminate artificial nails for all persons who provide direct patient care.

________________________ __________________________ Resident Name Resident Signature

_______________________ Department

Riverside Medical Center Department of Education

2014 Spotlight on Safety Post-Test

H:\RIVERSIDE HOSPITAL\SOS\2014 Edition\2014 SOS Test & Key\2014 RMC SOS Test.docx

Section A to be completed by ALL Employees

1. Kaiser Permanente’s Mission Statement states: “Kaiser Permanente exists to provide affordable, high quality healthcare services to improve the health of our members and the communities we serve.” What are the three major components of our Vision that guide our behavior to achieve our Mission?

a. How we relate to each otherb. How we workc. How we define successd. All of the above

2. (Answer Questions 2 – 9): To call an Emergency Code on the Riverside Campus dial ext. 7777Match the codes below

a. Code Red __ __ Stat Calls – Security Assistance

b. Code Orange __ __ Infant Security System

c. Code Blue __ __ Cardiac or Respiratory Arrest, (baby up to 15lbs)

d. Dr. Duber __ __ Cardiac or Respiratory Arrest, (over 13yrs)

e. Code Pink __ __ Fire

f. Code Secure __ __ Cardiac or Respiratory Arrest, (baby, 16lbs-13yrs)

g. Pediatric Code blue __ __ Internal or External Disaster

h. Code Silver __ __ Weapon/Hostage Situation

3. Skills and Techniques for De-escalating threat include all of the options except.a. Stay professional and in control of yourself - remain calmb. Invade their physical space and look them in the eyec. Listen carefully and empathetically for clues to the conflictd. Answer as many questions as calmly, clearly, quickly, and completely as you cane. Ask for third party help - do not hesitate to ask for help

4. Choose the correct sites or resources to find a QBS interpreter: (Every staff member is responsible to know how tolocate/obtain language services and know where and how to correctly document the use and/or refusal of suchservices in the patient’s medical record).

a. MY HR>KP& me tab ”Diversity”b. Staff listing could be found in Riverside Share (“S”) Drivec. Docushare intranet websited. All of above

5. KP staff must always offer patients free interpreter services and document the use or refusal of such servicesa. Trueb. False

6. Being aware and equipped to meet age related needs of our members will ensure quality care of the patients andmembers of all ages.

a. Trueb. False

7. All employees have responsibility to report actual and potential unusual events that may cause harm to members andvisitors, including unsafe systems and processes, by completing unusual occurrence reports-online (UOR-O).

a. Trueb. False

8. Annual Health evaluation includes:a. Annual questionnaireb. Current on mandated vaccinesc. TB skin testd. N95 Fit test for areas that require ite. Annual review of infection control practices and complete a post testf. All of the above

Riverside Medical Center Department of Education

2014 Spotlight on Safety Post-Test

H:\RIVERSIDE HOSPITAL\SOS\2014 Edition\2014 SOS Test & Key\2014 RMC SOS Test.docx

9. The Safety hot-line number in Riverside Medical Center is: a. 7777 b. 3626 c. 0 (Operator)

10. Who is responsible for safety in the unit/department?

a. Your supervisor b. Your safety officer c. All employees are accountable for working safely

11. What is the appropriate term to use when talking or writing about people with disabilities?

a. Confined to a wheelchair b. A person who uses a wheelchair c. Invalid d. Wheelchair bound

12. Service animals may or may not be wearing identifying markers.

a. True b. False

13. For large Chemical spills: Evacuate the area. a. Notify your Supervisor b. Call 7777 for administration spill response team c. Both a & b

14. Signs that someone is having a stroke may include: slurred speech, facial droop, and/or weakness of an arm or leg

especially on one side of body. a. True b. False

15. Legal Advance Health Care Directives (AHCD) are signed by the patient, and either: a. Two witnesses (one not a relative, or KP medical care program personnel, volunteer or Physician may not

serve as a witness for members). b. A notary c. Long term care legal Guardian, conservator if completed in a SNF d. Any of the above

16. Physician Orders for Life Sustaining Treatment (POLST) is a:

a. Physician Order recognized throughout the medical system in CA b. Directive for a range of end-of-life medical treatment c. Portable document that transfers with the patient throughout the medical system d. All of the above

Section B for Patient Care Providers to complete ONLY (16- 25)

17. 2014 National Patient Safety Goals Goal 6: Use Alarms Safely List two initiatives to improve outcomes. a. Make improvements on Medical Alarms b. And policies on response time c. All of the above

18. Care of Diabetic patients admitted to the hospital includes:

a. Get a Hemoglobin A1C b. Help prevent avoidable Hypoglycemic events c. Help prevent patient Re-hospitalization provide a smooth and safe transition from hospital to home d. All of the above

19. Principles of Pain Management:

a. Evaluate mechanism of pain (nociceptive, neurologic, visceral or muscle-skeletal) b. Use of the multi-modal approach c. Consider type and intensity to determine appropriate route of medications d. Consider characteristics of pain to determine frequency and dosing e. All of the above

Riverside Medical Center Department of Education

2014 Spotlight on Safety Post-Test

H:\RIVERSIDE HOSPITAL\SOS\2014 Edition\2014 SOS Test & Key\2014 RMC SOS Test.docx

20. The most reliable indicator of a patient’s pain is:

a. The patient’s self-report b. Whatever the experiencing person says it is c. Existing whenever he says it does d. It is what the care provider thinks the patient’s pain is e. a, b, & c only

21. New 2014 In-Patient Certification?

a. COEMIG b. LUNG Volume Reduction c. Inpatient Diabetes d. Stroke

22. Age related Competencies awareness and being equipped to meet their different needs will ensure:

a. Quality Care of our patients and members b. Help in the care plan and the evaluation of the effectiveness of care c. All of the Above

23. Adolescents: Are in Transition and therefore It would be essential to promote and encourage communication

between parents, teens and peers and clarify misinformation gathered form their peers. a. True b. False

24. Basic Radiation Safety Tips

a. RECOGNITION-Radiation sources are marked by the International Radiation Hazard Symbol, room label “Caution X-ray”

b. DISTANCE- Stay at least 2 feet away from any radiation source. c. SHIELDING- Do not remain or enter a room during X-ray exposures unless you are wearing a lead apron or

are standing d. Behind a lead shield e. TIME-Reduce your exposure time to radiation f. All of the above except b.

25. Kaiser Permanente Nursing Vision, Values, & Model is:

a. Patient and family-centered care b. Compassion, professionalism c. Teamwork, leadership d. Excellence, integrity e. All of the above

I have had an opportunity to have my questions answered.

Employee Name (Print Legibly) Employee Signature

Department Location Employee Number (REQUIRED) Date

Infection Control Orientation and Annual Review Clinical Post-Test 2014 1. Which of the following tasks require hand hygiene as described in the Five Moments of hand hygiene?

a. Before and after contact with the patient or their environment b. Hand hygiene is not required if there was no contact with the patient. c. Before accessing a central line d. After manipulating or making changes to the IV pump e. All of the above f. a, c and d

2. Standard Precautions is the first tier of precautions is used:

a. For all patients and at all times b. Regardless of the patient’s diagnoses or unknown infectious status c. Includes hand hygiene d. Requires the use of personal protective equipment (PPE) based on task and risk of exposure e. All of the above

3. Healthcare Associated Infections (HAIs) are one of the leading causes of preventable deaths in the US. Strategies to

prevent HAIs include: a. Hand Hygiene b. Wearing gloves every time you enter a patient room. c. Cleaning equipment between patient use d. All of the above e. a and c only

4. T F Hand hygiene is the single most important practice to reduce transmission of infectious agents. 5. T F Hand hygiene should be done in front of the patient along with verbal scripting. 6. T F When wearing gloves, hand hygiene is not required. 7. Strategies to prevent transmission of Clostridium difficile infection (CDI) include:

1. Use of soap/water for hand hygiene; (because alcohol based hand rubs do not kill spores). 2. Use of Contact Plus Isolation for patients with CDI 3. Judicious use of antibiotics 4. Environmental and patient equipment cleaning with bleach. 5. Wearing PPE (gloves and gown) upon entering the room

a. 1,3 and 5 only b. 3 and 4 only c. All of the above

8. Before entering an isolation room, what is the appropriate order for donning PPE?

a. Don gloves, gown then mask. b. Perform hand hygiene, don gown, mask then gloves c. Don gown, mask then gloves.

9. T F Patients placed into isolation must receive both written and verbal education related to their illness and the

education MUST be documented in the electronic medical record. 10. Strategies to prevent urinary tract infections include:

a. Verify daily that the patient continues to meet the criteria for a foley catheter b. Remove the foley as soon as possible c. Use alternatives to indwelling foley catheter such as condom cath, chux, etc. d. All of the above and more.

If you have any further questions or need additional information you can contact any of the departments listed on the first page of the IC Resource Book.

__________________________ ________________________ ___________ ___________ ___________ Print Name Legibly Signature Dept Employee # Date

' JJNWHHWtlHU

lternate ParkingSite

I pj^'i..'."1.111 n ^] U II ilillllll U ^