IU Health Bloomington Hospital
EMPLOYEE APPLICATION FOR STUDENT PLACEMENT
Name:
Employee Number:
Complete Address:
Contact Email Address:
Contact Phone Number:
Type of Experience:
__ SHADOWING
__ INTERNSHIP
__ CLINICAL
School/University/Program (if applicable):
Instructor Name and Email Address:
Have you already coordinated this requested experience?
__ YES
__ NO
If YES, please describe the agreement that you have made. Include contact name,
department/unit, schedule, and number of observation hours:
If CLINICAL STUDENT, indicate dept./unit and start and end date:
If NO, specify department/unit, profession, or specific employee name for requested placement:
If NO, please list dates and times you are available and requested number of observation hours:
In an emergency, notify (Name/Relationship/Phone Number):
Hold Harmless Agreement & Waiver
The undersigned, being an adult, does herby agree to release, indemnify, and hold harmless IU
Health Bloomington Hospital, its employees, agents, and representatives from any and all
damages of any nature whatsoever which the undersigned may suffer as a result of being a
passenger in a IU Health Bloomington Hospital vehicle, including an EMTS emergency vehicle,
owned or operated by IU Health Bloomington Hospital. The undersigned fully understands the risks
involved in being a passenger in an IU Health Bloomington Hospital vehicle, including any
emergency vehicle owned or operated by IU Health Bloomington Hospital, and assumes risk freely
and voluntarily. This release indemnity and holds harmless is given by the undersigned in
consideration of IU Health Bloomington Hospital granting permission to ride in a IU Health
Bloomington Hospital vehicle, including any emergency vehicle, owned or operated by IU Health
Bloomington Hospital for training, observation and evaluation purpose of benefit to the
undersigned.
Employees Who Shadow, Intern, or Participate in a Clinical Student Placement:
HR POLICY 2-106 (SECTION 106.5)
Employees who request to shadow, intern, or perform clinicals will not be paid. All assignments
should take place on the employee’s own time, not during scheduled work time without Director
approval.
Employees who desire to shadow a position, in regards to considering a job transfer, should first
contact the Human Resources Generalist responsible for the open position.
Employees desiring to shadow, intern or complete a clinical rotation, in relation to continuing their
education, should contact the Student Placement Coordinator to discuss paperwork requirements
(as they are different for employee versus non-employee). Employees who participate in a student
placement experience will not be required to have a health assessment or complete the
requirements outlined in Human Resources Student Placement Policy 2-106, but will be required to
submit this “Employee Application Form.”
Signature: ___________________________________________________
(Typing your full name qualifies as an electronic signature.)
Date: ________________________________________________________
HUMAN RESOURCES SECTION:
☐ Student Placement Name Badge Issued
HR Staff Signature:
Date: