Student Signature

First Name

Last Name

School Name

Instructor Name

Instructor Phone

Expected Start Date at BMC

I have read the on-line Student Orientation provided by Broadlawns Medical Center and understand the following topics:

^*Electronically initial when completed

For ALL Students

Confidentiality

Drug-Free Workplace

Equal Employment Opportunity

Equal Opportunity/Harassment Issues

Falls

HIPAA

National Patient Safety Goals

Patient Rights

Radiology Exposure

Safety Procedures

Service Excellence

Sexual and Other Types of Harassment

Statement of Mission, Vision and Values

Student Guidelines

Tobacco-Free Environment

For students in clinical internships - individual or group:

Drug Addiction in Healthcare Professionals

Infection Control

Mandatory Reporting

Multiculturalism in Healthcare

Right-to-Know

I will cooperate fully in following the health care organization's policies and protocols.

Name (Electronic)

Date: