Taa Short Term Observer Application

TRAINEE & ALUMNI AFFAIRS Regulations Concerning Short-Term Observers Short-term observers are appointed by Trainee & Alumni Affairs. This form must be completed and returned to Trainee & Alumni Affairs (Unit 165) 30 days prior to the first day of the appointment. Short-term observers are academicians and educational trainees who come to this institution for 30 days or less in a 12-month period. Short-term observers’ activities are limited to observation only. Short-term observers may not participate in patient care or research activities. Short-term observers may not provide service to the institution. Short-term observers may attend conferences and lectures. Those who are physicians or dentists may also observe clinics, the operating room and rounds in accordance with appropriate medical staff policy. Short-term observers are not provided a stipend. Housing, health insurance, and living expenses are the responsibility of the short-term observer. Short-term observers must submit documentation of a negative tuberculosis screen within the previous 12 months prior to beginning their appointment. Screening consists of a negative skin test (PPD) or, in the event of a positive PPD, a negative chest x-ray report. Short-term observers must complete the HIPAA privacy test for direct care providers. Non-U.S. citizens are required to check in with the Office of International Affairs (OIA) before the first day of the appointment. OIA is located at 7000 Fannin, Suite130, Houston, TX 77030. Non-U.S. citizens should bring all original immigration documents. All short-term observers are required to check in with Trainee & Alumni Affairs (TAA) prior to the first day of the appointment. Non-U.S. citizens must present their clearance form from OIA. U.S. citizens must present picture identification.

Revised 08/13/2007

Application for Short-Term Observer Appointment To be completed by the applicant (please print or type): Last or Family Name

First Name

Country of Birth

Country of Legal Residency

Country of Citizenship

If U.S. citizen, naturalized?

Visa Type (choose one):

B1/B2

F-1 Month

Proposed Start & End Dates

F-2 /

Degree

Middle Name

Day

/

J-1 Year

J-2

through

Yes

VWP Month

/

Day

No

Other: _____________ /

Year

Briefly state your goals and objectives in coming to M. D. Anderson Cancer Center as a short-term observer. What do you hope to learn? What outcomes do you expect to achieve? How will you measure those outcomes? Please be specific. (Attach a separate sheet if you prefer.)

Parent Institution Name (if applicable) Current Position at Parent Institution

Specialty:

Parent Institution Address

Street

City

State/Foreign Country/Zip or Mail Code

Permanent Address

Street

City

State/Foreign Country/Zip or Mail Code

Houston Address

Street

City

Zip Code

Primary Phone Emergency Contact

Cell Phone Name

E-mail Address Phone Number

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Relationship

Your activities at this institution are governed by The UT System Rules and Regulations, including the institutional Intellectual Property Policy (Policy IV.J.3.01). You will be expected to maintain the confidentiality of University proprietary information, and to obtain approval from your chair/mentor/program director prior to disclosing or publishing any results of your activities at M. D. Anderson. You may come into contact with health information while you are a short-term observer at M. D. Anderson. All health information is regarded as confidential and made available only to authorized individuals or as required by law. Release of any individually identifiable medical information for any purpose other than direct patient care, or research that ensures anonymity, must be done only with authorization of the patient or the patient's authorized agent. Applicant’s signature acknowledges that regulations concerning short-term observers have been read and understood, and that the information provided is complete, accurate, and not misleading to the best of his or her knowledge.

Applicant’s signature:

Date:

To be completed by M. D. Anderson department personnel (please print or type): Name of Department

Department Unit #

Department Contact

Phone number

Faculty Host (Name)

Phone number

Is trainee coming from a sister institution?

Yes

Signature of Department Chair, Deputy Department Chair, or Responsible Faculty

To be completed by Department of Trainee & Alumni Affairs: Approved Signature

Disapproved Please Print Name

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No Please Print Name

Unknown

HIPAA Privacy Training Please refer to the HIPAA Privacy Booklet (pdf file) to complete the final exam below. Click on the correct answer. Last or Family Name

First Name

Middle Name

Completion Date

1.

Which area is not addressed by HIPAA? a. Insurance portability b. Hospital accreditation c. Fraud enforcement d. Administrative simplification

2.

Which is the best description of covered entities under HIPAA? a. Hospitals only b. Hospitals and payers only c. Providers, clearinghouses, and most health plans d. Nursing homes, home health agencies, and hospitals

3.

What are the two kinds of sanctions under HIPAA? a. Egregious and inadvertent b. Criminal and civil c. Warranted and unwarranted d. Security and privacy

4.

What kind of protected health information is protected by the HIPAA privacy rule? a. Paper b. Electronic c. The spoken word d. All of the above

5.

True or False? Your organization must make any amendments to records that patients request. a. True b. False

6.

Under HIPAA, what is not an example of a health care operation? a. Education programs b. Medical record reviews c. Selling patient lists to a pharmaceutical firm for marketing their products d. Accreditation surveys

7.

What does HIPAA say about faxing patient information? a. It can only be done among providers b. All patient information must be de-identified c. It is not allowed d. You should ensure that the fax is secure. Examples of securing faxes may include sending to a secure machine or alerting the receiver that the fax is on the way.

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8.

Which of the following are some common features designed to protect the confidentiality of health information contained in patient medical records? a. Password protection b. Locks on medical records files or file room c. Rules that prohibit employees from looking at records without a need to know the information for their jobs d. All of the above

9.

When is patient authorization required? a. In most cases, when patient information is going to be shared with anyone other than for purposes of treatment, payment, or healthcare operations b. Upon admission to the hospital c. When patient information is to be shared among two or more clinicians d. When patient information is used for billing a private insurer

10.

You are on duty elsewhere in the hospital when you hear that a neighbor has just arrived in the EC for treatment. You should: a. Contact the neighbor’s spouse to alert them b. Do nothing c. Tell the charge nurse in the EC that you know how to reach the patient’s spouse if the information is needed.

11.

True or False: Confidentiality protections cover not just a patient’s health related information, such as their diagnosis, but also other identifying information such as Social Security numbers and telephone numbers. a. True b. False

12.

If you suspect someone is violating the institution’s privacy policy, you should: a. Confront the individual involved and remind him or her of the rules b. Watch the individual involved until you have gathered evidence against him or her c. Report your suspicions to the institution’s Compliance Officer, as outlined in your policy

13.

True of False: Computer equipment that has been used to store patient health information must undergo special processing to remove all traces of information before it can be disposed of. a. True b. False

14.

When disclosing patient information to another provider for the provision of treatment, should you limit the patient information you provide? a. No, you should provide all patient information, including the entire medical record b. Yes, you should provide only the minimum amount of information necessary for treatment c. Strictly speaking, you don’t have to limit information for treatment under HIPAA. However, good practices and most policies say to consider what’s being asked for. For instance, don’t send the whole medical record if only the current medical problem is involved.

15.

What is the Notice of Privacy Practices? a. A notice that is supplied to computer repair services to tell them what file formats our organization uses b. A notice required by HIPAA that tells all patients how their patient information will be used c. A notice included only in patient billing forms

To ensure that you receive credit for completion of HIPAA Privacy training, submit your answer sheet with your application for short-term observer.

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Tuberculosis Screening Tuberculin skin test (PPD) is required within the last 12 months, even if you have received BCG vaccination, unless documentation is submitted of a past positive PPD (10 mm or more induration.) Last or Family Name

Date:

First Name

Result:

Middle Name

Negative

†

measurement in mm.

Positive

†

measurement in mm.

If positive, did you take isoniazid (INH) prophylaxis?

Yes

†

No

†

Chest x-ray findings if PPD is positive, completed after positive skin test. Date of chest x-ray

Result:

†

No evidence of active tuberculosis

†

X-ray consistent with active tuberculosis

†

Abnormal x-ray, but not to due to tuberculosis

Attach x-ray report, and provide English translation if applicable.

Health Care Provider Signature Address Phone Number

Please Print Name City

State/Foreign Country/Zip or Mail Code Fax Number

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