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Name of Student: __________________________________ Email: School Attending: UC Berkeley School of OptometryProgram: OptometryUCSF Medical Center Department where you will be completing required hours: Ophthalmology and Optometry DepartmentUCSF Medical Center Manager/Supervisor: Rick SeefeldtYour school (Affiliate) has entered into an Agreement with UCSF Medical Center which states the following:Section I. H In compliance with Title 22 requirements and the Cal/OSHA Aerosol Transmissible Disease Standard, Affiliate assures that students have:Evidence of immunity to Measles, Mumps, Rubella and Varicella (appropriate documentation of vaccination or positive titer for each. Evidence of annual Tuberculosis (TB) screening in the form of:Two documented negative TB skin tests, one within 3 months and one within 1 year;Negative interferon gamma release assay ( IGRA); orNegative chest x-ray taken within the previous year if the student is TB skin test or IGRA positiveDocumentation of Tdap vaccinationDocumentation of the current season’s influenza vaccinationSection I. L. Affiliate must conduct a criminal background and sanction search for each student. The criminal background search must be performed by a third party consumer reporting agency and include a county criminal search in each county in which the individual has lived or worked in the last seven years; social security validation and trace; a sanction search conducted via the OIG and GSA database; and a search against the National Sex Offender Registry. If the background check reveals any convictions or charges pending adjudication, aside from minor driving violations, the affiliate must notify the Facility ( UCSF Medical Center). Final acceptance of student into the Program is the Facility’s determination. Student Responsibilities: Affiliate shall notify students in the Program that they are responsible for:Complying with Clinical Facility’s clinical and administrative policies, procedures, rules and regulations. Arranging for their own transportation and living arrangements if not provided by the Affiliate. Maintaining the confidentiality of patient information.No student shall have access to or have the right to receive any medical record, except when necessary in the regular course of the clinical experience. The discussion, transmission, or narration in any form by students of any individually identifiable patient information, medical or otherwise, obtained in the course of the Program is forbidden except as a necessary part of the practical experience. (REQUIRED PROVISION/HIPAA)Neither Affiliate nor its employees or agent shall be granted access to individually identifiable information unless the patient has first given consent using a form approved by Clinical Facility that complies with applicable state and federal law, including the Health Insurance Portability and Accountability Act (HIPAA) and its implementing regulations. (REQUIRED PROVISION/HIPAA)Clinical Facility shall reasonably assist Affiliate in obtaining patient consent in appropriate circumstances. In the absence of consent, students shall use de-identified information only in any discussions about the clinical experience with Affiliate, its employees, or agents; (REQUIRED PROVISION/HIPAA)Complying with Clinical Facility’s dress code and wearing name badges identifying themselves as students.Attending an orientation to be provided by the Clinical FacilityNotifying Clinical Facility of any violation of state or federal laws by student.Providing services to Clinical Facility’s patients only under the supervision of Clinical Facility’s professional staff.Students who come on UCSF premises must be covered under the Affiliate’s health insurance (this would be the primary provider of coverage in the event of an injury or illness.) 2691787261826By signing below, I confirm I have completed the requirements listed above as required in the Student Affiliation Agreement. I understand I am required to provide evidence of completion if requested by UCSF Medical Center. Name (Signature)DatePrint Name__________________________________________________________ Manager – please keep a copy for your records. ................
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