Registration

OLLIF CONFERENCE 2017 REGISTRATION FORM

OLLIF Conference 2017 Registration Form

INSTRUCTIONS:
Please fill out this form fully.  We will send email confirmation when we have received the application. You may contact knohl@tristatebrainspine.com with any questions regarding the conference.
  • Ex: MD, PhD, FAANS, etc.
  • Employing Institution
  • Position at Above Institution
  • (This is how you will be contacted regarding conference correspondence)

OBSERVATION FORM: STUDENTS AND MISC. OBSERVERS

  • At least 1 business day of prior notice is required for processing.
    OBSERVATION FORM: STUDENTS AND MISC. OBSERVERS

    (no direct patient contact)


    Fairview Ridges Hospital Surgery Department
  • ("Observer")
  • (list estimated start and end dates, typically less than one month)
  • All Observers Must Read and Complete the Following Information


    Fairview Health Services ("Fairview") supports visiting observers who desire to gain medical knowledge during the observation of patient care procedures and activities at the Hospital. In exchange for this observation experience, the Observer agrees to the following terms during the observation period: 
    • Observer has obtained proper approval from Fairview and the Hospital for the observation experience and will be sponsored by a physician credentialed to provide patient care at the Hospital. The sponsoring physician will provide Observer with opportunities to observe the physician performing patient care and/or clinical teaching duties and will oversee the activities of the Observer to help ensure compliance with the terms of this observation agreement.
     
    • Observer understands that he/she must be accompanied by the sponsoring physician when observing patient care activities and that he/she is not allowed independent access to patients or patient records (electronic or hard copy). Observer agrees to comply with all Fairview identification procedures which may include wearing an observer badge with photo ID. Observer and sponsoring physician will clearly identify the Observer to all patients encountered and observation of patient care activities will only occur after the patient has given permission for the Observer to be present.
     
    • Observer agrees to comply with all applicable policies and procedures of Fairview and the Hospital, including but not limited to policies on observer/visitor rules, equal opportunity/non-discrimination and protecting patient confidentiality. Observer will not disclose or discuss patient identifiable information with any persons except with other healthcare providers involved in the patient's care as needed to facilitate the observation experience. Observer will also follow the requirements of HIPAA to the extent applicable and acknowledges the obligation to protect patient confidentiality forever, even after the observation period has expired.
     
    • Observer will not provide medical care to patients during the observation period. Observer understands that medical care includes, but is not limited to performing any of the following functions: taking a medical history; performing a physical examination; diagnosing or treating a patient's condition; prescribing or administering drugs; writing notes or orders in a patient's chart; performing or assisting in a surgical procedure; or billing for services rendered. Observer further acknowledges that providing medical care to patients in violation of this agreement may result in civil liability, licensing sanctions or criminal penalties.
     
    • Observer will not be considered an employee/staff member of Fairview, the University of Minnesota or of any independent physician group providing services at the Hospital. Observer will not be entitled to salary, benefits, reimbursement of expenses or other compensation. Observer understands that he/she will not be provided with liability coverage or medical insurance during the observation period and will not be covered by workers' compensation coverage if injured during the observation period. Observer certifies that he/she has health insurance coverage which is valid in the United States.
     
    • Observer will not receive any academic credit for this experience and will not be considered a student, resident, fellow or trainee of Fairview, the University of Minnesota or of any independent physician group providing services at the Hospital.
     
    • Prior to the start of the observation period, Observer will provide documentation of immunity from infectious diseases using the attached Health Screening Form. Observer agrees to refrain from patient care observation at any time that Observer has infectious disease symptoms which could be transmitted to patients.
     
    • If the Observer is not a citizen or permanent resident of the United States, Observer will warrants that he/she has appropriate visa status which authorizes the Observer to be present in the United States and allows the Observer to participate in this observation experience. Documentation shall be provided to Fairview upon request.
     
    • Fairview may terminate the observation experience at any time and in its sole discretion by providing notice to the Observer. Observer acknowledges that no appeal or grievance rights exist to challenge the termination of an observation experience.
     
    • Observer releases Fairview and its affiliates, the Hospital, the University of Minnesota, all independent physician groups providing services at the Hospital and their respective employees, directors, agents, and other representatives from any responsibility or liability for personal injury (including death and damage to or loss of property) that Observer may incur due to the negligence of Fairview and its affiliates, the Hospital, the University of Minnesota, any independent physician group providing services at the Hospital and their respective employees, directors, agents, and other representatives, or due to accidental occurrences arising from activities relating to this observation experience.
      

    [SIGNATURES REQUIRED ON FOLLOWING PAGE

    AND HEALTH SCREENING FORM MUST BE COMPLETED]

      Observer warrants that he/she has read this observation agreement, understands its contents and will abide by the terms of this agreement.


  • Fairview Health Services Hospital Representative

    Name: Sharon Spies


    Sign: __________________________

    Title: Clinical Learning Specialist

    Date: __________________________

    Completed forms and health screening forms must be returned to the Sharon Spies



  • FAIRVIEW HEALTH SCREENING FORM


    REQUIRED & RECOMMENDED HEALTH IMMUNIZATIONS



    The following health immunizations are required of all Observers who are visiting patient care areas.
    • MMR (measles, mumps and rubella): 2 vaccinations are required.
    • Varicella (chickenpox): 2 vaccinations are required or a positive history of the disease.
     The following health immunizations are required of all Observers who will have close patient contact.
    • A negative TST test (Tuberculosis Skin Test or Mantoux): Observers must have a negative 2 step TST test or negative blood assay M. tuberculosis (BAMT) in their medical history with annual negative TST or BAMT. Observers with a positive TST test must have a negative chest x-ray test within the 12 months prior to the program visit and negative annual symptom survey.
    • Hepatitis B Vaccination Series: A 3 shot Hepatitis B vaccination series is required for Observers who may have contact with blood or bodily fluids. Or the Observer must document their decision to decline to be vaccinated against Hepatitis B.
    • Varicella (chickenpox): 2 vaccinations are required, or documentation of positive titers, or physician certified medical documentation of a positive history of the disease.
    • Annual Flu Shots (influenza): Annual flu shots are required.
     The following immunization is recommended, but not required, for visiting patient care areas.
    • Pertussis (t-dap) Vaccination: One-time vaccination after age of 19.
     Observers in need of vaccinations must obtain them from their private physician. Fairview does not provide vaccinations or testing to Observers.


  • INFECTIOUS DISEASE CHECKLIST



    Within the past 3 weeks have you had or been exposed to:


  • Do you currently have any of the following:


  • If you answer "YES" to any of the above questions or do not meet the immunization requirements listed above, then you must obtain specific Fairview approval before the observation experience may begin and your participation may be declined for the benefit of our patients. Observers should work with their Fairview liaison to obtain clearance, if possible, through the Infection Control Dept. or through Employee Health Services. Patient safety has the highest priority and observers who may pose a risk of infectious disease exposure cannot be allowed to have patient contact without specific Hospital approval. Thank you for your consideration of our patients.