Job Shadowing Forms | Mercer Health

Observer / Job Shadowing Questionnaire + Confidentiality Statement

Name(Required)

First Last

Age:(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Phone(Required)

Please list the department(s) you are interested in job shadowing:(Required)

Please list the specific role(s) you are interested in job shadowing (physician, nurse, respiratory therapist, social worker, etc.):(Required)

Date(s) & time(s) available for job shadowing:(Required)

Grade Level(Required)

High School Student

College Student

Grade(Required)

School(Required)

College Student(Required)

Job Shadowing

Required Observation for college requirement

Please list college:

Please list program enrolled in:

Please list number of hours needed:

Observer / Job Shadowing Confidentiality Statement

During your visit to Mercer Health, you may see or overhear patient information. Patient information is confidential and protected by law. Because of this, you must follow the rules below while you are here.

Cell phones are not permitted in clinical areas. You may not have your cell phone out during any shadowing experience. If you are found using your phone or taking photos, you will be asked to leave the facility immediately.

You Must:

Respect the privacy and confidentiality of our patients.
Wait outside the patient’s room until the person you are shadowing has received the patient’s permission for you to enter.

You Must Not:

Enter a patient’s room unless permission has been granted by the patient.
Access a patient’s chart or view patient information electronically. The person you are shadowing must limit the information you are exposed to.
Copy, remove, or take identifiable patient information with you.
Provide treatment or assist with patient care.

You must keep all patient information confidential after your visit. If you are required to write a report or give a presentation for school, do not describe patients in a way that could identify them. You may discuss patients with the person you are shadowing during your visit, but you may not discuss patients with anyone after your visit.

Failure to follow these rules may result in fines or criminal penalties. If your job shadowing experience is part of an educational requirement, your school will be notified and may take additional action.

Job Shadowing Requirements

Only students in high school or higher are eligible. The student must be currently attending or be a graduate of a Mercer County, or adjacent county, school system.
This is a short-term experience. Any ongoing arrangement must be coordinated through the Director of Volunteer Services.
Access to certain areas may be restricted.

If the student has had a PPD (tuberculosis) test within the last year, attach a copy of the results. If not, a one-step PPD test will be needed and can be obtained from your local health department or Mercer Health Occupational Health & Wellness Services who can be reached at 419-586-1220. There is a small fee for this test.(Required)

Yes, I have had a PPD (tuberculosis) test within the last year, and I have attached a copy of the results.

I am a current employee of Mercer Health or a Mercer Health Volunteer and my PPD is on file.

Please upload required proof of your one-step PPD as listed on the Job Shadowing Requirements.(Required)

Max. file size: 300 MB.

Student Signature(Required)

Date(Required)

Parent Signature(Required)

Parent signature needed for students under 18 years of age. Your signature indicates your approval for your child’s participation in the Job Shadowing program at Mercer County Community Hospital and acknowledgment that he or she is in good health.

Date(Required)

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