Immunization Form

Office of Graduate Medical Education
RE:
Visiting Medical / PA Student Registration, Access and Orientation
Dear Medical / PA Student,
You have been scheduled to participate in at least one clinical rotation at our hospital during the 2015 / 2016
Academic Year. In order to ensure that you have access to computer systems, locked wards, scrubs, etc. it is
necessary that you complete the attached packet of forms:
… Medical / PA Student Registration Form: Please complete all sections except for that indicating rotation start
and end dates and bottom section marked “This area for GME Office use only.”
… Card/Pin Control Card: Complete all yellow highlighted sections. In the yellow highlighted box that states “Pin
# issued to:” please put your initials.
… Riverside County Regional Medical Center Identification Badge Agreement: Please complete all sections
highlighted in blue, with the exception of Social Security number. As you are not one of our employees, it is
not necessary for us to obtain your Social Security number.
… Security & Confidentiality Statement: Please read and then initial where highlighted in blue. Sign, date and
print your name at the bottom of the form. The policies referenced in the statement will be reviewed with you
at orientation.
… PACS Log On Request: Complete all sections highlighted in blue. When writing your name be sure to
provide your middle initial if you have one. Your log on is your first initial, underscore, and then your entire
last name. Your password may contain numbers, but must begin with a letter.
… Scrub Wearer Form: Complete all sections highlighted in blue.
… Scrub Suit User Agreement: Complete and sign.
… Online Orientation Trainings:
We have several online orientation training modules that must be completed prior to you being permitted to
participate in clinical rotations. The first step in completing these orientation modules is to create a user
account in our online training system. To do this you will go to the following internet address:
http://www.rcrmctraining.org/
Once you are on the website, you will see a link on the upper right hand side of the web page titled “Login.”
Click on this link and when you are on the new page you will see a link to create a new account. Click on this
link and follow the instructions to create your account. Do not register as an employee, as you do not have
an Employee ID number. If it asks for an employee ID number, just enter “none”. You will receive a
confirmation e-mail once your account is created – this only takes a matter of minutes.
When your account is created you will log-in, go to the “Patient Care Orientation” section – in a box at about
the middle of the page – and click on the link for “Resident Physician and Medical Student Orientation” and
complete all of the training listed. Once you have completed all of the required training you will receive a
completion certificate. Please print the certificate and send to the GME Office along with the other
documents.
Parking: On the first day of your rotation please park in lot D. Once you have reported to our office on the
first day of your first rotation you will receive an employee parking permit. Once you have your employee
parking permit you may park in any lot designated for employees. A copy of the RCRMC parking map is
attached. We do occasionally have students choose not to put the employee sticker on their car and park in
26520 Cactu s Av enue, Mor eno V a lley, Californ ia 92555
PHON E: 951-486-5908 • FAX : 909-486-5910 • TDD : 909-486-4397
visitor/patient parking. This is absolutely prohibited. We have a parking hotline and employees who see
people parked in visitor/patient parking are encouraged to report them on this hotline. You will get a ticket if
you do this.
… Orientation / Computer Training: Orientation is held every Monday and on the first of the month at 7:00 am at the
GME Office, Rm. A1005. Computer training is also held every Monday at 12:30 pm in the CPC Building, Suite
203 (located to your right as you turn into the Nason St. entrance to the hospital). You will not be permitted to
start your rotation until you have attended orientation and computer training. For most of you the first day of your
rotation will fall on a Monday and you may complete these requirements on the first day of your rotation. If your
rotations begins on a day other than a Monday, you must complete the requirements in advance. If you would
like to complete the requirements in advance, please contact Keisha Arthur for availability. Keisha may be
reached at 951-486-5907 or via e-mail at [email protected].
Please complete all forms as indicated, do so LEGIBLY and do not complete sections you were not instructed to
complete. When printing out the forms, do not print them double-sided as the forms go to different hospital
departments. Mail all completed forms to:
RCRMC
GME Office, Rm. A1005
ATTN: Keisha Arthur
26520 Cactus Avenue
Moreno Valley, CA 92555
All forms and training certificates must be received at least 30 days prior to the start date of your
rotation. Your rotation may be cancelled if we do not receive your on boarding packet within this
timeline.
Thank you,
Denise Adams
GME Coordinator
CARD / PIN CONTROL CARD
Last Name:
First Name:
(Print)
Department:
(Print)
GME
(Middle Initial Required)
I understand I am responsible for the safekeeping of my pin number. Pin numbers must not be disclosed to anyone, not even supervisors or
managers. I also understand, I am the only one authorized to use my ID card to gain access to electronically controlled areas in the hospital.
Should I lose my ID card, I will report it immediately to Plant Operations and Human Resources Department. Upon my separation from
RCRMC, I will notify Plant Operations Access Control in person, so my records can be cleared.
Signature:
Date:
PIN # ISSUED TO:
PIN NO.
DATE ISSUED
Expected Graduation:
07/31/
(YOUR INITIALS ↓)
PIN # ISSUED BY:
DATE
CANCELLED
SIGNATURE
RIVERSIDE COUNTY REGIONAL MEDICAL CENTER IDENTIFICATION BADGE AGREEMENT
(Initial ↓)
I UNDERSTAND that the issued Identification Badge is the property of Riverside County, and I must surrender
the badge upon request.
I AGREE to wear the issued Identification Badge in a visible manner, picture side up, at all times while on duty.
I AGREE not to deface issued Identification Badge with pins, stickers, tape, or other materials in accordance
with the HSA Policy
I AGREE to surrender the Identification Badge upon any change in my employment, separation of employment,
or on the request of my Division Manager, Branch Chief, Supervisor, Administrator, or Human Resources.
I AGREE to immediately notify Human Resources should the Identification Badge be lost, stolen or damaged.
I AGREE to pay a replacement fee of $10.00 for a lost, stolen or damaged Identification Badge before I will be
issued a replacement or receive my final paycheck.
I AGREE to permit my badge photograph to be released to the RCRMC Office of Graduate Medical Education
to be maintained in their trainee database.
I HEREBY AGREE to abide by all of the above mentioned conditions to receive an Identification Badge, and
understand that should I fail to comply with conditions of this agreement, I will be subject to disciplinary action.
ID BADGES MAY BE OBTAINED MONDAY – FRIDAY FROM 7:30AM – 4:00 PM
PLEASE CHECK ONE OF THE FOLLOWING BELOW:
EMPLOYEE’S SIGNATURE ACKNOWLEDGING AGREEMENT
CONTRACT
X
EMPLOYEE
EMPLOYEE’S NAME (PLEASE PRINT)
INSTRUCTOR
/
/
SOCIAL SECURITY NUMBER
OTHER:
DATE
--EMPLOYEE NUMBER
Medical Student
Medical Student
MEDICAL PER DIEM POOL
POSITION TITLE (DO NOT ABBREVIATE, WRITE OUT TITLE COMPLETELY.)
CONTRACT PHYSICIAN/SURGEON
RCRMC
GME
DEPARTMENT NAME
WORK LOCATION
SECURITY
Denise Adams
STUDENT
MANAGER’S NAME (PLEASE PRINT)
T.A.P. EMPLOYEE
MANAGER’S SIGNATURE
DATE
VOLUNTEER
TO BE COMPLETED BY HUMAN RESOURCES:
REPLACEMENT BADGE
ID BADGE #:
OLD ID BADGE COLLECTED
OLD ID BADGE NOT COLLECTED
DAMAGED BADGE COLLECTED
DAMAGED BADGE NOT COLLECTED
LOST OR STOLEN
RECEIPT ATTACHED
NEW ID:
DATE:
HR INITIALS:
Re-revised (07/05) G:\STF-CLAS\RCRMC\HR Forms & Procedures-RCRMC ID Badge Agmt.2005.DOC
PACS LOG ON REQUEST
Your Log on is to consist of the first letter of your first name, an underscore and
your last name, all in lower case. Example: John Smith is j_smith.
Password: Please use a password that will be easy for you to remember but
secure. It must begin with a letter but can contain numbers. Passwords will be
entered into the PACS system as lower case. Please do not use capital letters.
Example: whole12
Return this form to Elizabeth Kleiner, Network PACS Supervisor in Diagnostic
Imaging Department. If you have any questions the phone number is 64079. We
are located in RM# F1070 in Diagnostic Imaging.
NAME:
(include middle initial & degree, i.e. MD, DO, RN, etc.)
LOG ON:
PASSWORD:
6-5908
PHONE:
Graduate Medical Education
DEPARTMENT:
Rotating Medical Student
TITLE:
IF RESIDENT, INTERN, PA or MEDICAL STUDENT, PLEASE INDICATE:
Start Date:
Rev. 06/06
End Date:
Radiology Department Use Only
Date Entered into PACS:
Date Deleted from PACS:
Riverside County Regional Medical Center
Scrub Suit, Wearer Identification
This Area To Be Completed By Wearer
Last Name _______________________
First Name _____________________
Employee ID# ____________________
Phone Extension __ 6-5907
Occupation
Anesthetist/Anesthesiologist
Graduate Medical Education
Department / Unit / Entity
Nurse
OR Staff
Size
Pharmacist
Physician
Physician/Assistant
X-Small
Small
X-Large
2X
Resident
Medium
3X
Student
Large
4X
Surgeon
Technician
Vendor
Other (specify)
I acknowledge receiving access to a complement of 3 Scrub Suit sets. I will wear the apparel in accordance with
RCRMC policies, and return items to be professionally laundered.
Wearer Signature
Date
This Area To Be Completed By Supervisor / Coordinator
Select all machines needed
Machine Location
A.
O.R.
B.
L&D
C.
EVS
µ
µ
µ
Expiration Date (Optional: Students, etc.)
Denise Adams
Supervisor Name, Printed
Supervisory Signature
Date
This Area To Be Completed By Human Resources / Material Management
ScrubEx 5-digit ID Badge Access Code
H. R. Signature / Material Management Signature
Date
revised 09-12-2012
Riverside County Regional Medical Center
Parking Map
Parking Lot C. E. F
Patient Parking
Only
No Staff
Parking Lot B
Patient Parking
and after -hours
6:30pm – 7:30am
Staff parking
Parking Lot G
Gated Physician
Parking
Parking Lots A, D,
H, I, & J for use by
staff, visitors and
patients
B Patient Only
I
J
C Patient Only
Motorcycle/ Carpool
H
Parking will be strictly enforced
continuous 24/7
G
F Patient Only
E Patient Only
D
Cactus Avenue
4/15/13
Nason Entrance
A