Student/Observation Application

In order to ensure safety for our patients and our staff, students and observers will
be required to fulfill various requirements prior to approval for placement.

Please ensure you click the submit button at the end of this form otherwise your application will not be received or processed. 

The "Save & Return" button is enabled on this form - if you do not have all your required documents, or need to return to the form to complete it, the form will provide a "return link". Please note, save and return does not indicate that the application has been submitted. 

 

Notice: Applications will take approximately

2-3 weeks to process.

Please have all your documentation prior to filling out this application; you will be required to upload documents (including vaccination, certifications, and a badge photo) to fulfill the requirements of this application. Accepted document types include, PDF, JPEG, or PNG.

Please limit cell phones pictures when uploading vaccination forms/documents as they are typically in the wrong format and are low in pixels. 

Required Documents:

• Background Check: You are not required to upload this document as the facilitating organization will send results directly to us for review. An email link will be send to you upon initial review of your application if its required depending on your student/observation requirements. 
• Urine Drug Screen: 10-Panel Screen: You are not required to upload this document as the facilitating organization will send results directly to us for review. An email link will be send to you upon initial review of your application if its required depending on your student/observation requirements.Agency staff will not need to obain a urine drug screening as long as your agency can produce up to date records of your previous screening. 
• Vaccination Requirements:
  • Measles, Mumps, and Rubella (MMR)
  • Hepatitis B
  • Varicella (Chicken Pox) 
  • Tdap
  • TB Skin Test (within 12 months)
  • Annual Influenza Vaccination
    • Required when rotation dates will fall between October 19th and March 31st 
•  Covid-19 Annaul Vaccination/Booster or Signed Declination Letter
• Students who wish to file an exemption for vaccinations must submit to their academic facility and request an exemption.
• Cheyenne Regional cannot grant exemptions for individuals, however we will honor exemptions granted by the academic center.
• Exemptions will not be allowed for those that are doing an observation rotation only.
• Basic Life Support Certification (BLS)
  • Must be certified through the AHA
  • See additional documentation below for further explanation.
    • Not all rotation types require this.
• Color Vision Test
  • See additional documentation below for further explanation.
    • Not all rotation types require this
    • Prior to clicking the link below to complete test, please note you must save the test results to upload into this application.
      • Click here to complete color vision test (A new tab will open with this link)
         

Notice: CRMC/CRMG employees are still required to complete this application, however additional documentation will not be required unless deemed necessary after initial application review. CRMC/CRMG staff documentation for the above requirements may exist with Occupational Health/HR.

Student Information

This application is for students that have secured a placement at CRMC.  If you have not secured a preceptor or department for your rotation please contact Kerrie Twito.

Background Check Requirement

To initiate a background check, you will receive an email from Universal Background. 

You will need to complete the information in the background check and pay your fee within 30 days of your clinical rotation start date.  The fee for this background check is approximatly $85.00.  Universal Background check will confidenitally send your results to the Cheyenne Regional's Student Onboarding Coordinator. Results must be obtained prior to clearance.

Notice: Background checks are not required for observation rotations or for current Cheyenne Regional Employees.

Urine Drug Screen Requirement

Cheyenne Regional requires a urine drug screen prior to the start of any type of rotation.

The screening must include a 10-panel drug screen, which includes fentenyl.  It is acceptable to obtain this test at any drug screening facility.

 

Things to keep in mind:

• Some facilities make take up to 2-3 weeks to process results, so please ensure timely testing. 
• Urine drug screens must be completed within 30 days of the start of student rotations. 
• Screening results MUST be sent to Cheyenne Regional's Student Onboarding Coordinator.
  • Fax number: 307-632-1006

All fees associated with the urine drug screen are the responsibility of the student.

Urine Drug Screens are not required for observation rotations or for current Cheyenne Regional employees.

 

Immunization Requirements

Being a future member of healthcare in any setting will require you to obtain and maintain required vaccinations. Cheyenne Regional requires anyone participating in a rotation or onsite instructors to maintain regulatory required immunizations.

Any fees associated with immunizations are the students responsibility.

 Measles, Mumps, and Rubella

You must obtain a full vaccination for MMR or provide a titer showing immunity.  Please provide the dates below and upload documentation from your provider. Documents from your school are not accepted and must be from a healthcare provider.

 Hepatitis B

You must obtain 3 doses for full vaccination of the Hepatitis B, or you may provide a titer showing immunity. Please provide the dates below and upload documentation from your provider. Documents from your school are not accepted and must be from a healthcare provider. 

 

Varicella 

You must obtain 2 doses for full vaccination, or you may provide a titer showing immunity. Please provide the dates below and upload documentation from your provider. Documents from your school are not accepted and must be from a healthcare provider. 

TB Skin Test 

The TB skin test must be resulted within the last 12 months. If unable to complete this test due to a previous position result it is required to have a chest x-ray less than 12 months upon entry into the organization and completion of a CDC TB questionnaire. 

Tdap

You must provide record of vaccination performed in the last 10 years. Please provide the dates below and upload documentation from your provider. Documents from your school are not accepted and must be from a healthcare provider.

 

Influenza Vaccination

Influenza vaccination is required for students/ instructors who will be on site between October 19th and March 31st. Provide documentation with lot number is required. Documents from your school are not accepted and must be from a healthcare provider.

Covid-19 Vaccination Observation

Annual Covid-19 vaccination records are required for those that participate in observation/student experiences.

Proof of vaccination from your school are not accepted and must be from a healthcare provider. 

Please note: Observation students are required to obtain an annual Covid-19 vaccination prior to placement at CRMC.

Click link to fill out a CRMC Covid-19 declination form, which provides proof that you are declining the annual Covid-19 vaccination/booster: Click here to open form

Basic Life Support Certification

BLS is required for the role you will be participating in while at Cheyenne Regional.  You must proivde documentation of a valid BLS certification card. Only American Heart Association BLS card will be accepted.

Your BLS expiration date must maintain valid throughout your clinical rotation.

BLS is not required for the observation or Non-Clincial Student rotations.

Color Vision Screening

A color vision screening required for the role you will be participating in while at Cheyenne Regional.   In the event that you are utilizing waived testing, you may need to use color to determine testings or screenings.  Use the following website to conduct your free color screening.

Color vision screening is not required for the observation or non-clinical rotations.

https://enchroma.com/pages/color-blindness-test  

Badge Issuance

Cheyenne Regional requires all students and instructors to identify themselves and their role via badge while on campus. To accomplish this, we require a professional headshot photo following the below guidelines: 

• Photo should be taken fully facing the camera
• No selfies
• With or without smile
• Without filters
• Avoid using driver license photos because of the issues our our software and the watermark 

Those participating in an observation experience will be provided a generic badge once they arrive to the unit. This badge must be worn at all times while on campus to identify yourself. It must be returned upon completion of the roation.

Notice: If submitted photos are deemed unuseable, the students will be required to produce another photo prior to receiving a badge and starting rotation. 

Cheyenne Regional Medical Center

WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT

I hereby release Memorial Hospital of Laramie County, Cheyenne Regional Medical Center ("HOSPITAL") for claims, expenses, damages, or liability for personal injury or damage to property, real or personal, that I may have or hereafter acquire, directly or indirectly, from the acts of HOSPITAL, its officers, boards, employees, faculty, students, interns, participants, medical staff, agents, and/or volunteers. I understand that my role at HOSPITAL will be to participate in the cooperative education program, which will include some patient treatment and care; provided, however my participation in any patient treatment and care will be subject to the agreement and consent of HOSPITAL, the patient and any applicable attending physician.

Further, I understand that I shall perform only those tasks delegated to me by HOSPITAL staff and/or the applicable attending physician. I further understand that I shall have no right of recourse, whether such right is one of due process or otherwise, against HOSPITAL in the event that HOSPITAL or my school terminate the Cooperative Education Agreement, which sets for the terms of my cooperative education experience at HOSPITAL, for whatever reason or in the event that HOSPITAL prohibits me from being present at HOSPITAL's facilities or from performing any services at HOSPTIAL. In addition, I acknowledge and agree that I am solely responsible for my own personal health insurance coverage throughout my cooperative education experience at HOSPITAL, and I acknowledge and agree that I am solely responsible for all medical expenses incurred during my cooperative education experience at HOSPITAL.

I am fully aware of risks and hazards connected with being on the premises and participating in the educational program.

Cheyenne Regional Medical Center

CONFIDENTIALITY AGREEMENT

It is the responsibility of all Memorial Hospital of Laramie County d/b/a Cheyenne Regional Medical Center ("HOSPITAL") workforce members, as well as persons present at HOSPITAL for clinical experience purposes such as students, interns, faculty members and other persons participating in the training, to preserve and protect confidential patient, employee, and business information. The federal Health Insurance Portability and Accountability Act ("HIPAA"), as well as State of Wyoming laws, govern the I release of patients' individually identifiable health information by hospitals and other health care providers and specify that such information may not be disclosed except as authorized by federal and state law or the respective patient or individual pursuant to an authorization in compliance with such laws. Confidential patient information includes:

• Any individually identifiable health information in possession or derived from a provider of health care regarding a patient's medical history, mental or physical condition or treatment, as well as the patient's and/or the patient's family members' records, test results, conversations, research records, and financial information.
  • Examples of information that would be protected under HIPAA include, but are not limited to:
    • Physical, medical, and psychiatric records including paper, photo, video, diagnostic and therapeutic reports, laboratory and pathology samples
    • Patient insurance and billing records
    • Mainframe and department-based computerized patient data and alphanumeric radio pager messages
    • Visual observation of patients receiving medical care or accessing services; · Verbal information provided by or about a patient
    • Name, addresses, Social Security numbers, geographic information, birth dates, admission dates, discharge dates.
    • Confidential employee and business information includes, but is not limited to:
      • Employee home telephone number, address, electronic mail path
      • Spouse or other relative names
      • Social security number or income tax withholding records
      • Information related to evaluation of performance
      • Other such information obtained from HOSPITAL records which, if disclosed, would constitute unwarranted invasion of privacy
      • Disclosure of confidential business information that would cause harm to HOSPITAL.

I understand and acknowledge that:

1. I agree to respect and maintain confidentiality of all discussions, deliberations, patient care records, and any other information generated in connection with individual patient care, risk management, and/or peer review activities.
2. It is my legal and ethical responsibility to protect, and I agree to protect, the privacy, confidentiality, and security of all medical records, proprietary information, and other confidential information related to HOSPITAL and its affiliates, including business, operational, employment, and medical information relating to HOSPITAL's patients, members, employees, and health care providers.
3. I agree to only access or disseminate patient care information in the performance of my assigned duties and where required by or permitted by law, and in a manner which is consistent with officially adopted policies of HOSPITAL or, where no officially adopted policy exists, only with the express approval of HOSPITAL's designated contact person or their designee. I agree to make no voluntary disclosure of any discussions, deliberations, patient care records or any other patient care, peer review, or risk management information, except to persons authorized by law to receive it in the conduct of HOSPITAL affairs.
4. HOSPITAL (administration, Privacy Officer, Security Officer, or Information Technology Department) may perform audits and reviews of patient records in order to identify inappropriate access.
5. My user identification (ID) is recorded when I access electronic records and I am the only one authorized to use my user ID. Use of my user ID is my responsibility whether used by me or anyone else. I will only access the minimum necessary information to satisfy my role or the need as requested by my designated faculty, HOSPTIAL contact person, or their designee.
6. I agree to discuss confidential information only while at HOSP ITAL and only as needed for cooperative education experience related purposes and to not discuss such information outside of HOSPITAL or within hearing distance of other people who do not have a need to know about the information.
7. That any and all references to HIV testing, such as any clinical test or laboratory test used to identify HIV, a compone1t of HIV, or antibodies or antigens to HIV, are specifically protected under law and unauthorized release of confidential information may make me subject to legal and/or disciplinary action.
8. That the law protects psychiatric and drug abuse records, and that unauthorized release of such information may be subject to legal and/or disciplinary action. My obligation to safeguard patient confidentiality continues in perpetuity after completion of my cooperative education experience at

By signing below I:

• Herby acknowledge that I have read and understand the foregoing information and that my signature below signifies my agreement to comply with the above terms. In the event of a breach or threatened breach of this Confidentiality Agreement.
• I acknowledge and agree that HOSPITAL may, as applicable and as it deems appropriate, pursue disciplinary action, up to and including my exclusion from HOSPITAL and the termination of the cooperative education experience.

Student Role/ Instructor Expectations

ROLE SUMMARY Cheyenne Regional Medical Center (CRMC or CRMG) supports the development of high- quality educational experiences for students entering the healthcare field.  Students will be partnered with skilled preceptors for the duration of their rotation.  Students will participate and perform care of patients or perform the department’s day-to-day activities under the direct supervision of the college’s designated faculty or Cheyenne Regional’s assigned clinical preceptor.  All tasks will be completed only upon the direction of Cheyenne Regional staff.  By participating in the program, the students agrees to:

1. Adhere to all hospital policies and procedures.
2. Uphold Cheyenne Regional’s behavioral standards at all times during the shadow/observation experience.
3. Maintain patient confidentiality standards according to HIPAA regulations.
4. Complete the application packet and provide Cheyenne Regional with all clearance documents within the time frames required.
5. Refrain from taking photographs, video, or audio recordings at any time during the experience and shall refrain from sharing their experience on social media.
6. Notify their sponsor and Onboarding Coordinator at Cheyenne Regional to reschedule their experience if they have a cold, fever, or other infectious diseases that would pose a health risk to Cheyenne Regional’s patients and staff.
7. Follow the Cheyenne Regional’s and/or academic organization’s dress code.
8. Identify themselves at all times while at Cheyenne Regional by wearing the appropriate hospital issued badge while on-premises.
9. Return their badge to the Clinical Education department at the end of their experience.
10. Notify the Onboarding Coordinator immediately of any problems that may occur during the experience.
11. Document in the computer and/or written permanent medical record after obtaining training through our EPIC training program.

Documentation must adhere to the Cheyenne Regional policy and procedure standards.  Documentation must be co-signed by either a preceptor or an Academic Faculty member.  

By signing below I verify that I have read and agree to the expectations required for completing an observation experience.

Student Role Expectations Nursing

ROLE SUMMARY Cheyenne Regional Medical Center (CRMC or CRMG) supports the development of high- quality educational experiences for students entering the healthcare field.  Students will be partnered with skilled preceptors for the duration of their rotation.  Students will participate and perform care of patients or perform the department’s day-to-day activities under the direct supervision of the college’s designated faculty or Cheyenne Regional’s assigned clinical preceptor.  All tasks will be completed only upon the direction of Cheyenne Regional staff.  By participating in the program, the student agrees to:

1. Adhere to all hospital policies and procedures.
2. Uphold Cheyenne Regional’s behavioral standards at all times during the shadow/observation experience.
3. Maintain patient confidentiality standards according to HIPAA regulations.
4. Complete the application packet and provide Cheyenne Regional with all clearance documents within the time frames required.
5. Refrain from taking photographs, video, or audio recordings at any time during the experience and shall refrain from sharing their experience on social media.
6. Notify their sponsor and Onboarding Coordinator at Cheyenne Regional to reschedule their experience if they have a cold, fever, or other infectious diseases that would pose a health risk to Cheyenne Regional’s patients and staff.
7. Follow the Cheyenne Regional’s and/or academic organization’s dress code.
8. Identify themselves at all times while at Cheyenne Regional by wearing the appropriate hospital issued badge while on-premises.
9. Return their badge to the Clinical Education department at the end of their experience.
10. Notify the Onboarding Coordinator immediately of any problems that may occur during the experience.
11. Document in the computer and/or written permanent medical record after obtaining training through our EPIC training program. Documentation must adhere to the Cheyenne Regional policy and procedure standards.  Documentation must be co-signed by either a preceptor or an Academic Faculty member.

In addition, the nursing student is held to the following expectations:

1. A student may administer medications by IM, IV, SQ, PO, SL rectally and/or topical routs as appropriate to the level of student skills and course objectives as taught by the school of nursing. However, the student is unlicensed, and as such, MUST administer all medications under the DIRECT/VISUAL supervision of the RN preceptor or Clinical Faculty Instructor.
2. Students may participate in skills/procedures previously performed in the school of nursing learning/skill/resource lab, and additional skills taught in the clinical area as long as they are directly supervised by the RN preceptor or Clinical Faculty Instructor.
3. The student must notify the RN preceptor, Clinical Faculty Instructor, and/or charge nurse immediately when an adverse patient outcome is identified.
4. The student will inform the RN preceptor or Clinical Faculty Instructor immediately when there is a change in the patient’s condition, or if any problem occurs with the patient, family, or equipment.
5. The student will provide a shift report to the primary nurse before leaving the floor for any reason and at the end of the shift.

By signing below I verify that I have read and agree to the expectations required for completing an observation experience.

Observation Role Expectations

ROLE SUMMARY Cheyenne Regional will provide a supervised educational experience according to agreed-upon objectives.  Observational visitors may not perform functions that are otherwise performed by employees or engage in patient care in any way.  Observational visitors may only observe the day-to-day tasks of the healthcare setting.  The sponsor is to accompany the visitor at all times while within the facility.  By participating in the program, the visitor agrees to:

1. Adhere to all hospital policies and procedures.
2. Uphold Cheyenne Regional’s behavioral standards at all times during the shadow/observation experience.
3. Maintain patient confidentiality standards according to HIPAA regulations.
4. Complete the application packet and provide Cheyenne Regional with all clearance documents within the time frames required.
5. Refrain from taking photographs, video, or audio recordings at any time during the experience and shall refrain from sharing their experience on social media.
6. Notify their sponsor and Onboarding Coordinator at Cheyenne Regional to reschedule their experience if they have a cold, fever, or other infectious diseases that would pose a health risk to Cheyenne Regional’s patients and staff.
7. Identify themselves at all times while at Cheyenne Regional by wearing the appropriate hospital issued badge while on-premises.
8. Return their badge to the Clinical Education department or the appropriate department at the end of their experience.
9. Notify the Onboarding Coordinator immediately of any problems that may occur during the experience.

By signing below I verify that I have read and agree to the expectations required for completing an observation experience.

Please review the above information for accuracy, please feel free to print a copy for your records and click submit to complete your application. 

The "Thank You" page will act as confirmation of a successful submission.

 

Reminder: Applications will take a minimum of 2-3 weeks to process.