Student Name: _______________________________ Page 1 of 16
Please print this entire file.
Complete all of the information and return it to your instructor or LVHN Office of Student Affairs in one stapled packet with the “REQUIREMENTS CHECKLIST” form on top.
In order for a student to be approved to begin, the orientation materials must be completed and received by the Office of Student Affairs at least two weeks PRIOR to any experience at LVHN.
Criminal clearances must be received prior to the start of the student’s educational experience at
LVHN.
LVHN OSA will email student and preceptor once the student’s paperwork is approved.
If required orientation documentation is not submitted at least two weeks prior, the student start date will be delayed until all required documentation is complete.
If the student is a current LVHN employee , in lieu of duplicating these requirements, please complete an Employee Orientation Exemption Form, as posted on www.lvhn.org/newstudent.
If the health and criminal clearance requirements have been met through an affiliation agreement with the student's school, the school should submit documentation that the requirements have been met.
Check www.lvhn.org/newstudent for School Documentation Form. In this case, each individual student need only submit this Documentation of Education.
Please send all documentation in one packet to:
Office of Student Affairs, Kasych-1st Floor
Lehigh Valley Health Network-Cedar Crest
PO Box 689
Allentown, PA 18105-1556
Fx: 610-402-8402
Direct all questions to:
Research Scholars:
Jean.Hoffman@lvhn.org - 610-402-2569
BTG CHIP Interns :
Margaret_A.Hadinger@lvhn.org - 610-402-2475
All Other Students
Jessica.Spack@lvhn.org - 610-402-2482
Additional Points to Consider:

If you will need computer access, please ask your preceptor/mentor/supervisor to request for you directly by submitting a WISAR request online. Call Information Services at 610-402-8303 with questions.

Your ID badge will give you “perimeter” access only. If you need access to any locked unit/department , please ask your preceptor/mentor/supervisor to request for you directly by emailing Tammy_C.Fullen@lvhn.org. Call Security at 610-402-8220 with questions.

Student Name: _______________________________ Page 2 of 16

Requirement:
LEHIGH VALLEY HEALTH NETWORK
Submit to:
Complete Health Certificate
Complete Quantiferon or 2 step TB testing
LVHN OSA
LVHN OSA
9 panel urine drug screen (pharmacy students only)
Complete CPSL affidavit
Complete PATCH request.
Copy of complete PATCH request.
When received, completed PATCH report.
Complete CAHC application, consent, and money order.
Copies of CAHC application, consent, and money order (completed report will be sent to LVHN OSA).
Complete fingerprinting for FBI Clearance consistent with the Child
Protective Services Law (CPSL).
Submit copy of COGENT form.
When FBI CPSL results are received, send copy .
Submit copy of RN license and professional liability insurance
(graduate nursing students only)
Send photocopy of school issued ID badge
Be sure to review LVHN “Orientation Documents” as posted on www.lvhn.org/newstudent . Your preceptor will provide more specific orientation to the particular department/unit where you will complete your experience.
LVHN OSA Comments:
LVHN OSA
LVHN OSA
PATCH
LVHN OSA
LVHN OSA
Submit to address on form.
LVHN OSA
COGENT
LVHN OSA
LVHN OSA
LVHN OSA
LVHN OSA

Student Name: _______________________________ Page 3 of 16
LEHIGH VALLEY HEALTH NETWORK
Name of Student: _____________________________________________________________________
Social Security Number: ________________________ DOB: __________________________________
(This information is REQUIRED and is used in our Security systems to create your ID badge and computer access)
Student Current Address _________________________________________________________________
Email ________________________________________________________________________________
Home Phone __________________________________ Cell Phone ______________________________
Emergency Contact Name _______________________________________________________________
Emergency Contact Relationship __________________________________________________________
Emergency Contact Phone _______________________________________________________________
School/Affiliation: _____________________________________________________________________
Start Date of Experience at LVHN: _________________ End Date: ______________________________
School Graduation Date: ________________________________________________________________
Course/Program Name: __________________________________________________________________
Area of Assignment(s): __________________________________________________________________
Or Preceptor’s Name: ____________________________________________________________
Please check all that apply:
.
are met and documentation attached.
Clearances information is completed and attached.
I have received education related to the following:
 Identification Badge Parking Assignment
 PRIDE Initiative LVHN – Hospital Plan for Provision of Patient Care
 Code of Conduct

Confidentiality

Rapid Response Team
Patients Rights and Responsibilities
Pastoral Care
Code Blue

Emergency Codes No Smoking Policy
 Administrative Dress Code and Dress Code Policy for Patient Care Services Requirements for Hand Hygiene for Hospital Personnel
 Patient Identification

Restraint and Seclusion Policies and Procedures/Restraint Alternatives

Employee Incident Report (Use for Student/Faculty Injury)

HIPAA
 Safety/Environment of Care
Domestic and Intimate Partner Violence
Patient Safety Report
Visitor Injury Reporting
General Safety
Security Management
Chemical Hazard
Communication
Waste Management
Accident Prevention Signs & Tags
Lockout/Tagout
Compressed Gases
Latex Allergy
Bloodborne Pathogens – Blood/Body Fluid Exposure
Emergency Management Tuberculosis and Respiratory Protection
Fire Safety

Patient Safety Part 1: Patient Safety Reporting: Pennsylvania MCARE/Act 13
 Patient Safety Part 2: JCAHO’s National Patient Safety Goals
 Fall Prevention LVHN Corporate Compliance
 Bridging Cultures: Delivering Culturally Appropriate Care

Stroke Alert

Behavioral Health Overview ( Applicable for Psychiatric Experience )
Interpreters
DVT
__________________________________________________
Student’s Signature
11/97,Rev. 8/98,8/99,1/01,1/03,5/03,8/03,8/05, 8/06,7/07, 11/08

Student Name: _______________________________ Page 4 of 16
Please check ALL that apply:

Are you 40-70 years old?

Veteran (other than Vietnam-era)

Vietnam-era Veteran (served on active duty between 08/05/64 and 05/07/75)

Disabled Veteran (Vietnam-era only)

Disabled Veteran (other than Vietnam-era)

Handicapped (person who 1} has a physical or mental impairment which substantially limits one or more of such person’s major life activities; 2} has a record of such impairment; or 3} is regarded as having such an impairment)
Ethnicity (please check ALL that apply)

White (not Hispanic or Latino origin). A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Black or African-American (not Hispanic or Latino origin). A person having origins in any of the black racial groups of Africa.

Asian or Pacific Islanders (not Hispanic or Latino origin). A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia,
China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Native Hawaiian or Pacific Islander (not Hispanic or Latino origin). A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

American Indian or Alaskan Native (not Hispanic or Latino origin). A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.

Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other
Spanish culture or origin, regardless of race.

Other
Gender

Male

Female
US Citizen

Yes

No
School requirement (please check ALL that apply):

This internship is required by my school.

This internship is required by my program/major.

I will receive credit for this internship.
Student will be participating in the Transitional Skills Unit (TSU) or in departments working in TSU (see list on www.lvhn.org/newstudent):

Yes

No
Residency (please check only one)

I am a resident of Pennsylvania and have been for at least two years.

I am a resident of Pennsylvania but have not been for at least two years.

I am not a Pennsylvania state resident.
* For LVHN purposes, students who reside in Pennsylvania during the time of their participation in educational programming are considered residents of Pennsylvania.
Have you ever been convicted of a misdemeanor or felony since your 16 th birthday?

Yes

No
If yes, please explain ___________________________________________________________________________

Student Name: _______________________________
Page 5 of 16

6

True or False
SAFETY
1. Prevention is the key to a safe and healthy workplace.
2. It is not necessary to fill out an incident report form if you told your supervisor about your work related injury.
SECURITY MANAGEMENT
3. Aggressive behavior, visitor falls, theft, vandalism are examples of emergency situations that should be reported to Security by dialing 555.
4. High-risk areas throughout LVHHN include the Emergency Department, Psychiatric units, Pharmacy and Pediatrics.
HAZARDOUS MATERIALS AND WASTE MANAGEMENT
5. Material Safety Data Sheets (MSDS) are available for all hazardous chemical products used at LVHHN and contain important information detailing how to handle the product in a safe manner.
6. Hazardous waste and infectious waste are the same waste stream.
7

7. Chemical products must be labeled by the manufacturer with appropriate hazard warnings.
8. It is not important to review a products MSDS sheet before working with that product.
9. Red bag waste costs approximately five times more to dispose of than regular waste.
10. We recycle cardboard, paper, aluminum, glass, and plastic at LVHHN.
LIFE (FIRE) SAFETY
11. Your first responsibility when you discover a fire is to rescue everyone in immediate danger.
12. Clean, uncluttered corridors are an important part of a successful Fire Safety program.
13. Fire extinguishers should be aimed at the top of the fire.
14. Fire Response -- Place in the correct order from 1 - being first to 4 - being last.
Contain/close doors Evacuate/extinguish small fires
Activate alarm ____ Rescue everyone in immediate danger.
EMERGENCY PREPAREDNESS
15. Dial 555 to report all Emergencies.
16. Emergency preparedness response only involves external emergencies.
EQUIPMENT MANAGEMENT

Student Name: _______________________________ Page 9 of 16
17. Critical Equipment should be plugged into red outlets because they are the only outlets that function during a power failure.

Student Name: _______________________________ Page 10 of 16
UTILITIES MANAGEMENT
18. The process of de-energizing and securing equipment is referred to as Lockout/
Tagout.
19. Matching - If you experience a utility failure, match the system with the department that you
1.
2.
3. would notify:
Water/Electrical outage
Computer
Telephone
A. Respiratory Therapy
B. Telecommunications
C. Information Services
D. Engineering 4. O
2
Supply
BLOODBORNE PATHOGENS
20. If you sustain an exposure to blood or body fluid and need additional information, you can call 402 - STIK.
21. Standard Precautions means that all blood and body fluids are considered potentially infected with a bloodborne pathogen.
22. The type of PPE you use depends upon the task you are performing.
23. You can wait until the end of your shift to clean the area that became contaminated with blood or body fluid.
24. The Exposure Control Plan is located in the Infection Control Manual.
TUBERCULOSIS
25. ___ Tuberculosis infection may be acquired when a person breathes in the tubercle bacillus from the air surrounding a person with active tuberculosis.
26. ___ You can wear an N-95 respirator without fit-testing and medical clearance.
27. ___ The Tuberculin Skin Test indicates whether you have been infected with tuberculosis.
Signature: __________________________________________________
Date Completed: _____________________________________________

11

Student Name: _______________________________ Page 12 of 16
June 2004, Reviewed August 2005, August 2006, November 2008

Student Name: _______________________________ Page 13 of 16

Student Name: _______________________________ Page 14 of 16
10.
11.
12.
9.
7.
8.
6.
5.
2.
3.
4.
TRUE OR FALSE:
1. _____ You see a stranger pick up a patient’s chart. You should stop him and ask for his identification.
_____ Nancy needs a new password. She uses her mother’s birthday and her father’s initials. The new password is 0323js34. This is a good password.
_____ Jeff can’t get into Lastword (Phamis). It’s okay for Donna to let him use her user ID and password during his shift.
_____ When sending a fax containing PHI, Kim should verify the correct fax number and include a cover sheet.
_____ Lisa receives an e-mail titled “LUV U 4 EVER” from Steve, a co-worker. Since she knows who sent the message, it is safe to open it.
_____ Jan is viewing a patient’s lab results on a computer workstation in the hospital. It’s okay for her to allow the patient’s daughter to view the results over her shoulder, because she is a nurse and works on the same unit as Jan.
_____ It’s okay to write your password down as long as the paper is kept out of the reach of others.
_____ It is okay to include Protected Health Information (PHI) in an external e-mail, as long as the recipient’s address has been double-checked prior to mailing.
_____ A patient’s immediate family should always be given access to the patient’s medical records upon request.
_____ Screen savers help keep Protected Health Information out of view.
_____ While riding a crowded elevator, Susan tells Ellen she must not enter Mr. Brown’s room in TTU because he is under isolation precautions. This was an appropriate location to share this information because they were not near the patient’s family.
_____ Unauthorized access to computer-based information can occur if a user does not sign off of the computer.

Student Name: _______________________________ Page 15 of 16
19.
17.
18.
16.
14.
15.
MULTIPLE CHOICE:
13. _____ What is HIPAA? a. Heparin Induced Platelet Aggregation b. Health Insurance Portability and Accountability Act c. Hospital Induced Pneumococcal Pneumonia d. Hospital Insured Poly-Pharmacy Administration Act
_____ Protected Health Information (PHI) consists of: a. Written or printed documents b. Computerized information c. The spoken word d. All of these
_____ What are the four categories of information at Lehigh Valley Hospital and Health
Network? a. Public, Private, Confidential and Restricted b. Unclassified, Private, Confidential and Restricted c. Public, Internal Use, Confidential and Restricted d. Unclassified, Internal Use Only, Confidential and Restricted
_____ Before releasing Protected Health Information (PHI) to anyone outside of the patient’s care providers, you should contact: a. The Nursing Unit Director b. Physician Relations c. HIM (Medical Records) d. All of these
_____ Viruses can enter the computer system in which of the following ways: a. Floppy disks b. Internet c. E-mail d. All of these three ways
_____ Which of the following is the first line of security for computer systems at
Lehigh Valley Hospital and Health Network? a. Passwords b. Screen Savers c. Locking Workstations d. All of these
_____ Which of the following is a good password? a. scooby8 b. 122333 c. drowssap d. 815ts90

Student Name: _______________________________
LEHIGH VALLEY HEALTH NETWORK
Page 16 of 16
I understand that as a employee of Lehigh Valley Hospital (along with its components and subsidiaries), member of the medical staff, physician office employee or non-hospital patient care provider or support personnel
(volunteer, intern, student , contractor, vendor, etc.), the performance of my job/duties may require me to access or become aware of the following confidential information:
-- Patient health care and financial information
-- Employee personnel, compensation and health care information
-- Physician performance and personnel information
-- Business information relating to Lehigh Valley Health Network
I understand that access to and use of this information in verbal, written or electronic (stored in a computer) form is a privilege. I also understand that access to information is granted to me based on business or clinical “need to know” standards and the responsibilities of my job as an employee or non-hospital patient care provider or support personnel.
I understand that I may not seek information that is not required to do my job. I also understand that I may share information only when necessary to do my job. I agree to store and dispose of information which I use in a way that ensures continued security and confidentiality.
I understand that the methods I use to get information may only be used in the performance of my job. If I require special authorization to access computer-based information, I understand that my computer sign-on information may only be used by me.
I also understand that I may not give my sign-on information to anyone, and that this information is the same as my written signature. I accept full responsibility for any use of my sign-on information.
I understand that Lehigh Valley Health Network has a Corporate Compliance Program and that I have been provided education regarding the program. I also understand that I have a role in preserving Lehigh Valley Health Network’s corporate integrity and thus have an obligation to report potential compliance issues. I was informed of the
Compliance Hotline number, 1-877-895-2905.
I declare that I have read and understand this acknowledgment. I have had an opportunity to ask questions and have them answered. I recognize that giving confidential information at any time during or after my employment or affiliation with Lehigh Valley Health Network may cause irreparable damage to Lehigh Valley Health Network, the patient or the health care provider. Accordingly, Lehigh Valley Health Network or the owner of such information may seek legal remedies against me, such as fine, criminal penalties, suspension or termination of employment.
Any employee who has concerns about the safety or quality of care provided in the hospital may report those concerns to the Joint Commission on Accreditation of Health Care Organizations: E-mail: complaint@jcaho.org
Fax: 630-792-5636 Mail: Office of Quality Monitoring, Joint Commission on Accreditation of Healthcare
Organizations, One Renaissance Boulevard, Oakbrook Terrace, IL 60181. No disciplinary action will be taken if an employee makes a report to JCAHO.
_________________________
Name
___________________________ ________________
Signature Date
I presented the material to the above signed person as per the guidelines in the Confidentiality Policy. I have given the above signed person the opportunity to ask, and have answered all questions.
____________________________________________________________
Signature/Title
_________________
Date