The facility is committed to protecting the privacy of all Residents and protecting the confidentiality of their health care information. The following specific principles are applicable to all the facility employees, independent health care professionals involved in the care of Residents at the facility, volunteers, students, faculty, vendors and contractors regardless of their job classification or position.

While working with Residents at/or the facility, I realize that I may have access to/or become aware of confidential Resident medical information, whether I am directly involved in providing care to that Resident. I understand that I must keep this information in the strictest of confidence. As a condition of my employment or work at the facility, I agree that I:

o Will not verbally or in any written form disclose confidential Resident information to any unauthorized person.

o Will not permit any unauthorized person to examine or make copies of any Resident’s records, reports, other documents, or data files prepared, controlled, or accessible by me at any time during or after my employment or work at the facility.

o Will not examine, use, or disclose confidential Resident medical information except as needed to perform the duties of my job.

o Will not knowingly include or cause to be included in any record or report, a false, inaccurate, or misleading entry.

o Will not remove or copy any record or report from the office where it is kept except in the performance of my duties.

o Will report any violation of this policy.

If I have access to computerized information or programs at the Nursing Home, I understand that the information accessed through all facility information systems contains sensitive and confidential Resident care, business, financial and Nursing Home employee information that should only be disclosed to those authorized to receive it. I commit to:

o Respect the ownership of proprietary software, by not making any unauthorized copies of software even when the software is not physically protected

o Respect the finite capability of the systems and limit my own use so as not to interfere unreasonably with the activity of other users.

o Respect the procedures established to manage the use of the system. o Prevent unauthorized use of any information in files maintained, stored or processed by the facility.

o Not operate any non-licensed software on any computer provided by the facility. Not utilize anyone else’s authentication code or device to access any of the facility system.

o Respect confidentiality of any reports printed from any information system containing Resident/member information and handle, store and dispose of these reports appropriately.

o Not release my authentication code.

o Understand that all access to the system will be monitored.

o Understand that my computer system privileges hereunder are subject to periodic review, revision and if appropriate renewal.

I understand that a violation of this agreement may result in corrective action up to and including discharge or termination of my student enrollment at Innovation Institute of Healthcare Solutions and that my obligations under this agreement will continue after termination of my student enrollment.

By signing this, I agree that have read, understand and will comply with the facility’s policies concerning confidentiality of information and use of computerized information systems and the statements made in this Agreement.

THIS STATEMENT is not a waiver.

I UNDERSTAND that due to my educational exposure to body fluids, blood or other potentially infectious materials or substances I may be at risk of acquiring Hepatitis B Virus (HBV) infection.

I UNDERSTAND that by declining the HBV vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease.

I UNDERSTAND I can obtain the Hepatitis B vaccination from my physician in the future if I continue to have educational exposure to body fluids, blood or other potentially infectious materials or substances.

I UNDERSTAND if I remain educationally at risk and I want to be vaccinated with Hepatitis B vaccine, as an active American Academy of Healthcare student I can receive the vaccination series from my physician.

MY SIGNATURE also acknowledges that I do not have a known sensitivity to yeast or a previous reaction to the vaccine that is known.

My affiliated health facility, Innovation Institute of Healthcare Solutions has recommended that I receive influenza vaccination to protect the patients I serve.

I acknowledge that I am aware of the following facts:

Influenza is a serious respiratory disease that kills an average of 36,000 persons and hospitalizes more than 200,000 persons in the United States each year.

Influenza vaccination is recommended for me and all other healthcare workers to protect our patients from influenza disease, its complications, and death.

If I contract influenza, I will shed the virus for 24–48 hours before influenza symptoms appear. My shedding the virus can spread influenza disease to patients in this facility.

If I become infected with influenza, even when my symptoms are mild or non-existent, I can spread severe illness to others.

I understand that I cannot get influenza from the influenza vaccine.

The consequences of my refusing to be vaccinated could have life-threatening consequences to my health and the health of those with whom I have contact, including my patients and other patients in this healthcare setting, my coworkers, my family, my community.

Despite these facts, I am choosing to decline influenza vaccination right now for the following reasons: