Confidential
PRACTICUM STUDENT DATA FORM
(Complete and return to Instructor 1st day of class)
Student Information:
Name: (information in column to right):
Please PRINT clearly.
Semester and year of Practicum:
Beginning Date at Practicum Site:
Tentative End Date at Practicum Site:
Days & Hours Scheduled at Practicum Site:
Phone number during Practicum (at site):
Phone number during Practicum (home):
Phone number, other (cell)
Mailing address during Practicum (home):
Including city, state, zip code
E-mail address:
Site Preceptor Information (Please Print):
Name:
Title:
Circle All
Applicable:
CCS
CCS-P
RHIT
Phone:
Fax:
E-Mail:
Site Information (Please Print):
Organization Name:
Department:
Street Address:
City, State, Zip:
Phone:
Student signature:
Davenport University, College of Health Professions, HIM Dept. (reviewed 04/2012)
RHIA
Confidential
PRACTICUM STUDENT CONFIDENTIALITY STATEMENT
Medical records and patient information are confidential for the protection of patients, families,
employees, medical staff, students/Students, and the healthcare organization. Confidential
information includes any information that a student hears or sees while conducting evaluation,
research, or educational activities at a healthcare facility. Patient privacy is to be respected at all
times. Breach of confidence is cause for immediate termination of the individual's educational or
Practicum affiliation with their Practicum site.
My signature below indicates the following:
1. I agree not to repeat or discuss, with any unauthorized individuals, confidential
information, which I may see or hear in conducting evaluation, research, or educational
activities while at my Practicum site, in the Davenport University classroom or computer
lab or in the AHIMA Virtual Lab.
2. I agree not to obtain or distribute any originals or copies of facility documents that are
considered confidential or part of a patient's medical record.
3. I agree not to obtain or distribute any originals or copies of patient health records or
patient information used to complete assignments in HINT294C, HINT296, and/or
HINT297C, whether stored as paper or electronic media or hybrid.
4. I understand that breach of confidence is cause for immediate termination of my
educational or Practicum affiliation with my Practicum site.
5. I understand that unauthorized release of confidential information may subject me to civil
liability under the provisions of state and federal laws.
Date: ________________Student Signature: _________________________________
Name (Print):________________________________________________________
School (Print):_______________________________________________________
Course Number and Name: ______________________________________________
Practicum Site: _______________________________________________________
Practicum Department: _________________________________________________
Witness Signature: ________________________________________
(Must be Practicum site or Davenport University employee)
Davenport University, College of Health Professions, HIM Dept. (reviewed 04/2012)