Participant packet packet contents

Colorado Area Health Education Center Program

In partnership with Central Colorado AHEC

2016 Summer Health Careers Institute

PARTICIPANT PACKET

PACKET CONTENTS

Participant Information	Pages 2- 3
Participant Contract*	Page 4
Participant Release of Liability Form*	Page 5-6
Participant Emergency and Medical Info./Waiver, Release, & Notice of Risk *	Pages 7-8
Participant Confidentiality Form*	Page 9

*These completed forms along with a copy of your immunization records and a negative TB test

need to be returned by Friday, July 15, 2016 to

Jennifer Hellier by mail in one envelope
Mail: Jennifer Hellier, PhD, Assistant Professor

Director of Colorado Health Professions Development Program (CO-HPD)

Associate Director of Programs

Colorado AHEC Program Office

University of Colorado - Anschutz Medical Campus

13120 E. 19th Ave, MS-F433

Aurora, CO 80045

2016 SUMMER HEALTH CAREERS INSTITUTE (SHCI)

PARTICIPANT INFORMATION

The following information will apply to participants in preparing for our five-day program from

August 1–5, 2016.
MEALS:
Participants to the SHCI will receive breakfast and lunch during the program.
If you have any food allergies or special needs, please be sure to complete and return the “Medical Release and Consent Treatment Form” by Friday, July 15, 2016.
OTHER INFORMATION:
Loss of Personal Property: The Summer Health Career Institute (including the Colorado AHEC Program Office, University of Colorado, and Central Colorado AHEC) will assume NO responsibility for theft, destruction, or loss of money or personal property. Participants should exercise every precaution in assuring the safety of their own property. Immediately, report to Michael Flowers or your Team Leader if any items that are stolen or missing.

1. 
   Transportation: Participants are responsible to transport themselves to each activity, either at the University of Colorado-Anschutz Medical Campus (13120 E. 19^th Ave, Aurora, CO 80045) or Community College of Aurora (9235 E. 10^th Drive, Denver, CO 80230). DPS will provide a shuttle bus for pick-up at CEC, George Washington, and Manual high schools. If you have questions, please contact:

   Karis Morrall

   
   720-423-6454
   Karis_Morrall@dpsk12.org
   

2. 
   Telephones and Technology: Participants will be asked to observe strict rules of etiquette and limits on personal cell phone use (i.e., turn off ringer and do not answer phone calls or text messages during classes, seminars, job-shadowing, etc.). In case of an emergency, please step out-of-the classroom to answer phone calls. These rules also apply to other devices (e.g., MP3 players, video, etc.). If a participant violates these rules, then the first time they will be warned and the second time the phone or device will be taken away.
   

3. 
   If a parent/guardian needs to contact a participant or if it is an emergency, please contact:
   

Mitch Fittro at 720-863-8199

or

Michael Flowers at 720-320-2386

PARTICIPANT EXPECTATIONS:
Participants will be learning about health careers by participating in program activities and understanding HIPAA privacy laws. We will use computers and work in groups to discover more about the world of work as it relates to health careers.
P.R.I.D.E. Participants will have the opportunity to show pride throughout the SHCI experience in each of the following ways:
Professionalism – We will be in professional environments and should match our attitudes and clothing to those environments. Participants will be expected to wear clothing that covers their cleavage, midriff and backside; no underwear should be exposed.

Respect – In the work world, it is imperative that we treat our hosts and each other with respect. This includes paying attention to our speakers without side conversations, and asking appropriate questions.

Integrity – Confidentiality will be a key component. Names and specific details that participants experience cannot be shared with anyone outside the group. The Health Insurance Portability and Accountability Act (HIPAA) protects specific patient information and strictly prohibits sharing this information without express consent from the patient.

Dedication – There will be assignments and expectations regarding completion of this program. Participants will be required to participate in all activities. Non-compliance will be cause for sending participants home.

Excellence – Participants are expected to give their best effort. The best way to ensure having a good experience is to approach this program with a “go-for-it” attitude.
WHAT TO BRING AND WHAT NOT TO BRING:

1. 
   Professional clothing must be worn most of the time. You will need to bring nice slacks/skirts (girls only) and nice shirts for most of the program agenda items. Include a warm sweater, sweatshirt or jacket for use in cool classrooms. Comfortable clothing, jeans, and shorts will be allowed for some activities.
   

Important Dress Code for Job Shadowing:

You will be in a health professional’s office, hospital, or clinic for your career experience and appropriate dress is required.  All students will be required to wear khakis/dress slacks/dress skirts (girls only), nice shirt or blouse with sleeves, and comfortable, closed toe shoes. No athletic shoes or sandals may be worn in a health clinic. Casual dress shoes are required; no high heels allowed. (Remember you will be standing and walking all day). We are serious about this requirement on this day. If you have any questions regarding appropriate dress for your career experience, please contact Mitch Fittro before coming to the Program. If you do not follow this dress requirement, you WILL NOT BE ALLOWED to participate in the career experience. NOTE: Closed toe shoes are required for job shadowing. Sandals and athletic (tennis/running) shoes will not be allowed during job shadowing.

2. Raincoat, windbreaker, rain poncho or umbrella for inclement weather.



2016 SUMMER HEALTH CAREERS INSTITUTE

PARTICIPANT CONTRACT
This is a contract between the University of Colorado, the Colorado Area Health Education Center (AHEC) Program, and Central Colorado AHEC and ____________________________________(name of parent/guardian), on behalf of,_______________________(name of participant), a participant in the 2016 Summer Health Career Institute.
During the time the Participant is at the University of Colorado or any other location as part of the above-referenced program, the Participant agrees to:

• 
  Commit to successfully complete the program;
  
• 
  Adapt to and learn from the environment and comply with all SHCI rules;
  
• 
  Be respectful of other participants, team leaders and staff;
  
• 
  Attend all scheduled meetings, classes, activities and work on time;
  
• 
  Turn in all assignments (if required) on time;
  
• 
  Meet with team leaders, teachers and other educators when scheduled;
  
• 
  Pay for any repairs or replacements of property damaged;
  
• 
  Not possess or use alcoholic beverages, marijuana, or any illegal substances while enrolled in the program;
  
• 
  Not smoke or use smokeless tobacco or marijuana while enrolled in the program;
  
• 
  Not possess or use any weapon or object of injury while enrolled in the program;
  
• 
  Not engage in sexual misconduct while enrolled in the program; and,
  
• 
  Not infringe upon the rights of the others participating in the program.
  

The Participant understands the Colorado AHEC Program provides meals and activity entrance fees during participation in the Summer Health Careers Institute at the University of Colorado. Valuable jewelry and property should be left at home. The University of Colorado, the Colorado Area Health Education Center (AHEC) Program, and Central Colorado AHEC staff are not responsible for lost or stolen property. The following expenses will be the Participant’s responsibility:

• 
  Any additional food, social/recreational activities that are not paid for by the program;
  
• 
  Charges for damaged property; and,
  
• 
  Any medical care or prescription drugs.
  

I have read the above and understand that failure to comply with any of these expectations will result in disciplinary action and possibly early program termination.

Participant’s Name_________________________________________Date ______________

Participant’s Signature ________________________________________________________

For Participants under 18 years of age

Parent/Guardian’s Name ____________________________________Date ______________

Parent/Guardian’s Signature ___________________________________________________



2016 SUMMER HEALTH CAREER INSTITUTE

PARTICIPANT RELEASE OF LIABILITY
I, __________________(parent/guardian), hereby give permission for _____________________ (name of Participant) to attend the 2016 Summer Health Career Institute (SHCI) sponsored by the Colorado Area Health Education Center (AHEC) Program, Central Colorado AHEC, and the University of Colorado. I understand that __________________________(name of Participant) will participate in all the sessions at the University of Colorado and various other locations.
I further understand that the University of Colorado, the Colorado Area Health Education Center (AHEC) Program, and Central Colorado AHEC will exercise reasonable supervision of all planned activities including any off-campus activities.
I understand that all participants must be in compliance with and abide by all the rules, regulations, and policies established by the University of Colorado, the Colorado Area Health Education Center (AHEC) Program, and Central Colorado AHEC. Furthermore, the University of Colorado, the Colorado Area Health Education Center (AHEC) Program, and Central Colorado AHEC will not be responsible for any accidents, injury or other misfortune which occurs as a result of a participant’s violation of these rules, regulations and policies, but will see that emergency medical care is provided.
RELEASE OF LIABILITY
This release of liability is executed on this day ___ in the month of , 2016, by the following participant, herein referred to as Releaser, in favor of University of Colorado, the Colorado Area Health Education Center (AHEC) Program, and Central Colorado AHEC.
In consideration of the participant being allowed to participate in the Summer Health Careers Institute, Releaser hereby acknowledges that I have had the opportunity to determine the nature of the activity and the manner in which it will be conducted and having such knowledge or having waived the right to obtain such knowledge do hereby personally assume all risks in connection with said activity and further release University of Colorado, the Colorado Area Health Education Center (AHEC) Program, and Central Colorado AHEC instructors, coaches, agents, employees, operators, officers, and trustees from liability for any harm, injury or damage which may befall the participant while engaged in this activity, traveling to or from the activity site or arising from the participant's presence at the site or in the site vicinity, including all risks connected therewith, whether foreseen or unforeseen; and further agree to save and hold harmless Colorado AHEC Program and the Regents of the University Colorado, and the above mentioned persons from any claim by me, the participant, or my family, estate, heirs, or assignees, arising from the aforesaid activity and circumstances.

Releaser states that I fully understand the terms herein are contractual and not a mere recital and that I have signed this document of my own free act. Releaser states that I have fully informed myself of the content of this release by reading it before signing it and verifying that I am 16 years or older.

Participant’s Name_________________________________________Date ______________

Participant’s Signature ________________________________________________________

For Participants under 18 years of age

Parent/Guardian’s Name ____________________________________Date ______________

Parent/Guardian’s Signature ___________________________________________________


Camp Information


Participant Information


Emergency Contacts AND Persons Authorized to Pick up Participant


Parent/ Guardian Information

Primary Name ______________________________________________________________________________________

First Middle Last

Home Address _____________________________________________________________________________________

Street Address City State Zip

Phone: Cell (____) _____-____________ Home (____) ____-____________ Work (____) _____-___________x________

Secondary Name ___________________________________________________________________________________

First Middle Last

Home Address _____________________________________________________________________________________

Street Address City State Zip

Phone: Cell (____) _____-____________ Home (____) ____-____________ Work (____) _____-___________x________

Other Name _______________________________________________________________________________________

First Middle Last

Home Address ______________________________________________________________________________________

Street Address City State Zip ________


Campus/Department/Camp Name: Summer Health Careers Institute – DPS – CO AHEC Program

Camp Dates: August 1, 2016 to August 5, 2016


Name ________________________________________________________________________________

First Middle Last

Grade in School ______________ Age _____________ Date of Birth _______________________________

Home Address __________________________________________________________________________

Street Address City State Zip


Physician _____________________________________________________________________ Phone (_____) _____-____________

Medical History (If necessary, use additional sheet) Date of Last Tetanus Booster ________________

Allergies: Insect bites/stings  Describe _______________________________ Drug  Describe _____________________________

Food  Describe ___________________________________ Other  Describe _______________________________________

Is participant under the care of a provider for either medical or psychological reasons? Yes  No 

If yes, please explain _______________________________________________________________________________________

____________________________________________________________________________________________________________

Is participant taking medically prescribed medication? Yes  No 

If yes, please explain _______________________________________________________________________________________

____________________________________________________________________________________________________________

Other information of which we should be aware? ____________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________



This two-page document is required for all participants and is not valid if either page is missing.


(Page 1 of 2) Participant Emergency and Medical INFORMATION

1. 
   I exercise my own free and voluntary choice to participate in the designated activity, including use of facilities and equipment provided by the University of Colorado, the Colorado Area Health Education Center (AHEC) Program, and Central Colorado AHEC. I understand and assume all associated risks of the designated activity. These risks may include, but are not limited to:
   

Health Assessment activity: finger prick to test blood glucose; Health Careers Expo and Simulation lab: taking vital signs/C-collar transportation/Splinting/ Hygiene/Suturing. During the cadaver lab experience, some smells from chemicals may be detected. However, the cadaver is on a specialized gurney with a down-draft to reduce exposure to chemical inhalation.

2. 
   I agree to assume all risk of personal injury or loss, bodily injury (including death), damage to or loss of, or destruction of any personal property resulting from or arising out of participation in the designated activity. I also release, waive, indemnify, hold harmless, and discharge the University of Colorado, the Colorado Area Health Education Center (AHEC) Program, and Central Colorado AHEC from all claims, damages, and injuries arising out of my activities, including my use of equipment and facilities provided by the University of Colorado, the Colorado Area Health Education Center (AHEC) Program, and Central Colorado AHEC.
   
3. 
   The University of Colorado, the Colorado Area Health Education Center (AHEC) Program, and Central Colorado AHEC do not provide health insurance for individuals participating in activities made available or sponsored by the University of Colorado, the Colorado Area Health Education Center (AHEC) Program, and Central Colorado AHEC. As such, you or your personal health insurance will be responsible for payment of medical services and care for any injuries sustained during the designated activity.
   
4. 
   To the best of my knowledge, I am free from any known health condition that could hinder or prevent active participation in or otherwise jeopardize the well-being of others in the Camp. By signature below, I affirm that I am in good health and that participation in the camp will in no way aggravate any health condition. I will seek medical advice as appropriate. I authorize Camp operators to act in their best judgment in treating any injury that I may sustain during Camp and agrees that all costs associated with such treatment will be at my expense.
   
5. 
   I agree to, and understand the importance of, following rules and regulations as set forth by camp leaders to minimize risk to myself and others. I will not bring or possess any items, which might endanger Participant or others (such as knives, weapons, alcohol, tobacco, marijuana, and/or illegal drugs). Possessing the above or serious violation of rules may result in immediate dismissal at Camp Operator’s sole discretion.
   
6. 
   I understand that participants in the University of Colorado, the Colorado Area Health Education Center (AHEC) Program, and Central Colorado AHEC events are sometimes photographed and videotaped for use in promotional and education materials. I understand that such audio, video, film and/or print images may be edited, duplicated, distributed, reproduced, broadcast, and/or reformatted any form and manner without payment of fees. I authorize the University of Colorado, the Colorado Area Health Education Center (AHEC) Program, and Central Colorado AHEC to record and photograph my image for use by the University of Colorado, the Colorado Area Health Education Center (AHEC) Program, and Central Colorado AHEC or its assignees in research, educational and promotional programs.
   
7. 
   I hereby certify that I have read and understand the provisions above. For participants under 18 years of age, the parent or guardian accepts the above terms and grants permissions for the student’s participation on behalf of said minor, as permitted by C.R.S. § 13-22-107. Participant exercises free and voluntary choice to participate in the above-referenced Camp, including use of facilities and equipment provided by the University of Colorado, the Colorado Area Health Education Center (AHEC) Program, and Central Colorado AHEC.
   

Participant’s Name ______________________________________________________________Date ______________

Participant’s Signature _____________________________________________________________________________

For Participants under 18 years of age
Parent/Guardian’s Name _________________________________________________________Date ______________

Parent/Guardian’s Signature ________________________________________________________________________

(Page 2 of 2) Participant Waiver, Release, and Notice of Risk





2016 SUMMER HEALTH CAREERS INSTITUTE

Participant Confidentiality Agreement

Dear Participant:

As part of the 2016 Summer Health Careers Institute, you will be visiting and participating in learning and educational activities in numerous healthcare facilities. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) demands strict standards of confidentiality from healthcare workers, as well as participants and visitors. You will be participating in a HIPAA training session as part of the program, in preparation for your job shadow experience. In the course of this program, you may have access to certain data and information that is considered confidential, including, but not limited to information about patients or business practices.
You are therefore asked to sign the confidentiality agreement below:
I agree that any and all data and information that I may receive or otherwise discover while observing is considered "Confidential Information". I agree that I will not disclose or discuss any Confidential Information while I am a Participant in the Program or at any time after my Program is completed. I agree that I will keep such data and information confidential and will comply with all laws and regulations concerning the confidentiality of such records to the same extent as such laws and regulations apply to the University of Colorado, the Colorado Area Health Education Center (AHEC) Program, and Central Colorado AHEC or other facilities in which I am job shadowing. I further agree that after my Program, I will return to the University of Colorado, the Colorado Area Health Education Center (AHEC) Program, and Central Colorado AHEC or to any other facilities in which I am job shadowing any and all documents and copies that I have in my possession that contain Confidential Information.

Participant’s Name_________________________________________Date ______________

Participant’s Signature ________________________________________________________

For Participants under 18 years of age

Parent/Guardian’s Name ____________________________________Date ______________

Parent/Guardian’s Signature ___________________________________________________

Revised March 2016

Directory: wp-content -> uploads -> 2016
2016 -> 2017 afoCo Landmark Scholarship Program
2016 -> Instructions for the Preparation of Camera-Ready Contributions to the Conference Proceedings
2016 -> Step student Scholarships for Year 10-13
2016 -> The united church of canada
2016 -> Idan raichel biography – May 2016 Brief Producer, keyboardist, Lyricist, composer and Performer Idan Raichel
2016 -> An introduction to centre’s interventions expanding access to justice
2016 -> Sanchar Shakti
2016 -> Unit analysis should help here. We want number of bananas
2016 -> The Autobiography of Elder Joseph Bates
2016 -> The Great Heat and the Rhode Island Deep Water Bay Scallop (Argopecten irradians) Fishery 1875-1905