Clinical Visitor Checklist


Name____________________________________ Dept____________________________ Mentor_____________________________ Date_______________________

Checklist REVISED – June 28, 2023


Clinical Visitor Checklist:                  Shadowing Guidelines          FAQ

VISITOR PROTOCOL


The Academic Clinics allow shadowing in accordance with ECU Health tiers and adherence to the requirements below.

The Brody School of Medicine welcomes visitor applications from recognized formal enrichment programs and individual applicants who are working with an identified mentor/supervisor. ALL applicants must complete the Visitor Checklist in its entirety and submit 10-14 days prior to their proposed shadowing experience for approval.

Visitors in the clinics should be introduced as observers to patients and responsible parties. It should be clear that the observer is not a health care worker. The patient or responsible party must give consent for the visitor to be present. Consent can be verbal and should be noted in the medical record. The shadowing student should not be asked to perform any procedures, handle any blood or body fluids or sharps, radioactive material nor hazardous chemicals.

    Please complete the following in preparation for your visit. Please complete all items, in their entirety, before submitting.

      • Visitor_Application – Ask your mentor/supervisor to sign and approve your form.

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      • A Current Copy of your Health Insurance Card. If you are doing practicum, also include Malpractice coverage.

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      • Verification of a Negative Tuberculin Skin Test within the past year.
        –Tests available from ECU Student Health Services, local health departments and your primary care provider.

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      • Clinical_Immunization Health History –Please include a copy of your health record to verify your MMR series, HepB series, Varicella series, Tdap, and also a current flu vaccination if you will visit during the months of Oct. – March.
         

      • Sign the Risk_&_ReleaseWaiver. –If you are under the age of 18, please have your waiver notarized.

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      • Sign the ECU COVID Waiver –If you are under the age of 18, you are not eligible to sign for yourself.

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      • Take the HIPAA Training module.  on https://canvas.ecu.edu
        –Students are required to complete HIPAA training annually. Contact our office for enrollment.

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      • Read the Bloodborne_Pathogen_TB_Review and take this Blood_Borne_Path_TB_Quiz.
        –Read the training module. Upon completion download/take the quiz and include it with your application.

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      • We would like you to take some additional training. If you will be working in direct patient care for a practicum, clinical rotation, or internship, please do the in-depth clinical AHEC Core Training and turn in your certificate. Please view all, paying special attention to the section on Covid-19.
        If you are doing research outside of the clinic, please do the following training modules and turn in the confirmation with your packet. Covid-19 Training Tool and ECU/OSHA Covid-19 Guidance

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      • Read the ECU Code_of_Conduct. Download/sign the Attestation.

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      • If you are doing laboratory research, please take the online training in chemical hygiene and laboratory safety at our Environmental Health and Safety website: http://www.ecu.edu/cs-admin/oehs/ih/Laboratory-Safety.cfm. form.

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      • Students who are onsite for research may need to take additional training depending on the nature of the research project. Please ask your PI if you need need to be added to the Institutional Biosafety protocol for labs BL-3 or greater or if you need training to work with lab animals or to register to work with radioactive materials .

       
      Please Read the Clinical Dress Code and FAQ for important information before your visit.

      If you will be in the hospital or a shared area, complete the following for ECU Health:

      If you are a high school student who will be shadowing for your Health Sciences class, or for Health Sciences Academy, contact the Health Careers office at ECU Health, 252-847-1773.

      If you will be shadowing a credentialed provider (MD, APRN, PA, AA, PhD) for a term up to 3 weeks, contact the Medical Staff Support office at 252-847-4534 for an updated hospital application.

      If you will be doing practicum or hands-on training for your degree program, contact the ECU Health Center for Learning and Performance, 252-847-4917.

      Please allow a two week processing period for your ECU Health Medical Center clearance.


By signing this checklist I attest to having fulfilled the requirements listed above.

Signature___________________________________________ Date ____________________________

If student is under the age of 18 a parent or legal representative must verify that these requirements have been met.

Parent/Legal Guardian Signature___________________________________________ Date ____________________________

In-person Documentation review is by appointment only. If you wish to meet in person for this, please call 252-744-3484 or email robinsonc@ecu.edu to arrange a time to review your paperwork. For your convenience, a dropbox is available in Brody 2N45 or you can scan and send via email.

Please allow 10-14 business days for processing before planning your visit. Paperwork will be considered complete after verification and review. Please submit requirements in full. Incomplete/partial submissions may delay your application clearance.