Shadow Application Form

You have reached out to Carolinas Rehabilitation, located in the Charlotte area. Please complete this application form if you are interested in obtaining shadow/observation hours. Each participant selected may only shadow a maximum of 16 hours overall per year. You must be 16 years or older to participate in the shadow program.

Once you complete the form, click the submit button at the bottom. Then return to the application website to complete the privacy test and submit your answers. A member of our team will review, process, and reach out if additional information is needed. Please note an application can't be processed until the privacy test is received.

Shadowing Process: Site leaders receive approved* shadows for the upcoming month at their site via email. (i.e. August Shadows will be communicated the last Thursday in July). If you are sent to a site leader, you will receive an email from Volunteer Services letting you know. Once sent to a site leader, they will you via email within 10 business days to set up shadowing dates and times. Facility and location are assigned randomly. We are unable to reassign site locations. Shadowing needs to be completed within 6 weeks in 4-8-hour increments.

We are Carolinas Rehabilitation, we have multiple locations in the greater Charlotte community. Thank you for your interest in our shadow program.

Name and address

First name:

Last name:

Nickname:

Street 1:

Street 2:

City:

State:

* Zip: *

Preferred Phone Number phone:

Other phone:

Email address:

Demographic Information

You may optionally provide the following information. It is used only to help us get a better idea of the demographic make-up of our volunteers.

Date of birth:

* (year optional)

Age:

Gender:

Education:

Major degree:

School:

Availability

Please indicate the days and times you are usually available to shadow. We provide shadowing Monday-Friday, morning and afternoon. Please note Shadows are sent to site leaders once a month. All shadowing is to be completed within 6 weeks of contact from site leader, in 4-8-hour increments.

Please also indicate when you must have shadow hours completed by if this is a school requirement or any other availability preferences in the empty box below.

Please note we do not provide evening or weekend shadowing in the therapy department.

Reason for Shadowing

Please write a short paragraph on why you desire to shadow/observe and the discipline.

We primarily provide shadowing of Therapy and Nursing Teammates.

Please note - MD shadowing will require the shadow to have obtained approval from the MD prior to applying.

Each participant selected may only shadow a maximum of 16 hours overall per calendar year.

Emergency Contacts

First name:

Last name:

Home phone:

Work phone:

Cell phone:

Relationship:

Health Status

It is required that all shadows be in good health the days they are shadowing and have received a recent TB Test with in the last year, Hepatitis B vaccine series, and flu vaccination.

Shadowers may be in proximity of immunocompromised patients and these requirements are for the the safety of both parties.

** All sections must be completed. Blank answers will not be accepted.

TB Test Health Requirement

In the box below please indicate the month/day/year and results of last TST (Tuberculin skin test/”TB test”)

a. If negative and within the past year, no further testing required.

b. If positive, was a chest x-ray performed? Please indicate Yes or No along with results and treatment (if any).

*N/A is not an acceptable answer.

Month/Day/Year

Hepatitis B Vaccine

Please indicate in the box below if you have you received the Hepatitis B vaccine series?

a. If No, did you have a positive Hepatitis B surface antibody test?

Yes or No

Flu Vaccination

Please indicate in the box below if you have had the Flu Vaccination for the current flu season?

* Required October - Spring.

Month/Day/Year

Good Health Confirmation

Please indicate in the box below if you are you in good health, with NO cough, fever, or diarrhea?

Dress Code Standards

**You may be sent home or asked to reschedule your shadow hours if these dress code standards are not followed**

Carolinas Rehabilitation has the same expectations of job shadowing candidates as employees regarding our dress code. Our philosophy is that candidates should be neat, clean, sanitary and pleasing in appearance to present a positive image to our patients and visitors. Unprofessional appearance may be associated with poor patient care. Our goal is to exceed our patients’ expectations.

Job shadowing candidates must meet the following dress code standards:

o Pants must be full length to the tops of shoes so that ankles are not visible when standing.

o Blouses/shirts should be constructed so that the top of the shoulder is covered. No halter tops, tank tops, strapless tops, spaghetti straps, or bare-shouldered tops of any type will be allowed. Midriffs should not be exposed.

The following attire is NOT appropriate and should not be worn.

o Scrubs

o Jeans (any color)

o Denim

o Athletic clothing

o Gauchos

o Shorts

o Capri pants or crop pants

o Tank tops

o Flip flop shoes

Permanent or temporary body art (tattoos) must be hidden or covered by clothing.

No visible body piercing jewelry (nose, lip, tongue, eyebrow, etc.) with the exception of earrings will be allowed. Only two earrings are allowed per ear. For safety reasons, no dangling earrings or excessive jewelry should be worn around patients or in hazardous work areas.

Body odor that is offensive to others cannot be tolerated. This may include heavily scented colognes, perfumes or after shave lotions.

Fingernails should be clean and neatly trimmed.

Candidates must wear their name badges at all times while job shadowing (A shadow nametag will be provided). Name badges should be worn with the front facing outward and on the collar of your shirt so it is readily visible to others.

Shadow Agreement

By checking below, I confirm that all information provided on this application is accurate. I also confirm that I will follow all safety, infection control, confidentiality, dress code, identification, decorum, and security requirements and policies at all times, as well as any other policies and practices I am directed to follow. I confirm that I have read, understand and agree to the following:

Privacy and Confidentiality

o I understand that confidentiality and privacy are very important, and that I may be exposed to confidential patient information and Atrium Health proprietary information in written, oral, or electronic forms.

o I understand that I must read, complete, and pass the test on privacy and confidentiality before I can start shadowing.

o I understand that Atrium Health could be fined up to millions of dollars for violating patient privacy rights, and that the patient and government will be notified in the event of a breach of privacy.

o I understand that my duties of confidentiality are indefinite, and continue after my shadowing is over.

o I will not reveal to anyone any information that I learn about a patient, whether from the patient or as a result of discussions with others providing care. This includes not disclosing the name or identity of any patient to anyone, nor revealing any other information that might identify them.

o I will not use, disclose, copy, download, photograph, record, access or text any confidential information, including patient information or information that belongs to Atrium Health.

o I will not take pictures of Atrium Health workforce, visitors, or patients, including on my smartphone.

o I will not post any information that identifies Atrium Health, its workforce, patients, or visitors on social networking sites.

o I will not write or publish any articles, stories, papers, blogs, postings, etc. that contain any patient or information or from which the patient’s identity can be learned. If I am allowed to take notes, I will do so in any way that does not identify the patient. If I write a paper about my shadowing/observation experience, I will submit it to supervising department or practice for prior approval.

o I will not access any medical records systems at any time, document in any medical record, nor use anyone’s login.

Behavior and Restrictions

o I will not misrepresent myself as a clinical student, resident, or health care provider at any time.

o I understand the patient must agree to my observing the encounter and that I may not be allowed to participate.

o I will not offer opinions on diagnosis or methods of treatment to patients or family members, nor do anything that could be construed as treatment. I am here only to observe and will not interact independently with patients.

o I understand that infection control is very important to patient safety, and I will comply with these requirements, including hand washing and any required vaccines.

o I am not an employee, contractor, or representative of Atrium Health and I will not be compensated or paid.

o My shadowing experience may be restricted and/or terminated at any time and for any reason.

o I will wear my Atrium Health-issued badge at all times and will return the badge when my shadowing participation is over.

By checking below, I also understand that there are inherent risks in being in a treatment environment, and I assume and accept those risks. I (including my representatives, heirs, and assigns) hold harmless and release Atrium Health, its subsidiaries, board members, officers, employees, workforce, and representatives (collectively, Atrium Health) from any harm, injury or damage that may arise, directly or indirectly, from my shadowing participation, whether caused by Atrium Health, me, or a third party. I also agree, on behalf of my representatives, heirs, and assigns, to indemnify Atrium Health from and against any damages, claims, causes of actions, penalties, or liability arising from or related to my acts or omissions during or related to my shadowing participation.

I Agree