Internship Application

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

Are you an Aultman Employee? Yes No

Have you completed an internship with Aultman previously? Yes No

What degree are you pursuing Certificate Associate Bachelor Master Doctorate

Aultman Internship Site Aultman Hospital Main Campus Aultman Orrville Hospital Aultman Alliance Community Hospital Aultman Woodlawn Aultman Massillon Aultman Carrollton Aultman North Aultman Tusc Other

My experience is not occurring during flu restriction season (November 1 – March 31st)

This immunization is required for all student experiences at Aultman.

Compliance: 
All members of the Aultman workforce including non-employee participants are expected to comply with the Code of Conduct, as well as all applicable policies and procedures, laws, regulations and contractual obligations. 
I understand that I am required to report any compliance concerns or issues to a member of the management team, the Compliance Office, or the Aultman Compliance Line (1-866-907-6901). 
I understand that individuals who appropriately report concerns will not be punished.

Conflict of Interest
Conflicts of interest may arise in a variety of circumstances. A conflict of interest occurs in situations where a non-employee participant and/or an employee’s judgment could be affected because of a personal interest in the outcome of a decision over which the non-employee participant and/or the employee has control or influence.
I do not have any financial, business, personal or other relationships that conflict with Aultman’s interests, or I have disclosed all actual and potential conflicts of interest to a member of management or the Compliance Officer. 

Confidentiality:
Most clinical and business records contain confidential information.  All employees and non-employee participants have a legal and moral responsibility to maintain confidentiality at all times. 
I agree not to disclose confidential information without proper authorization.
I agree not to review records or files for which I do not have authorization, including the records of co-workers, family and friends. 
I agree not to remove confidential information from Aultman without approval to do so.
I agree not to make copies of any records or data except as required to perform my duties. 
I agree not to use any Aultman records or data for personal use or for commercial purposes. 

Electronic Communications:
All electronic communication systems and the information transmitted by, received from, or stored in these systems are the property of Aultman Health Foundation.  
I understand that these systems are to be used solely for job-related purposes and not for personal use.
I understand I have no expectation of privacy in connection with the use of these systems. 
I agree not to access a file or retrieve stored communication without authorization.
I agree not to share my password with anyone. 
I agree not to use another person’s id to gain access to any electronic communication system. 

Violation of any of the standards listed on this form may result in expulsion from Aultman Health Foundation programs and could result in potential legal action.

I have received, read, and understand the Personal Appearance guidelines. I understand that if I do not follow the Personal Appearance guidelines that I may be sent home to change or provided scrubs to wear.

Effective Monday, January 3, 2011, Aultman Hospital will implement the second phase of its Tobacco-free Campus initiative. This initiative will strengthen Aultman’s commitment to a healthy workforce and community. As a part of this program, Aultman will be taking the following steps:

Aultman’s main campus, off-site facilities and other properties will continue to be tobacco-free.

Students will no longer be able to participate in their educational experiences if they smell of tobacco products and will be asked to leave the premises & are not permitted to use tobacco products during their experience at Aultman.

I have received and reviewed the Safety Education. I am responsible and accountable for the information in the education packet.

I have received and reviewed the HIPAA education. I am responsible and accountable for the information in the education packet. I will adhere to the HIPAA guidelines as stated in the education packet.

I have reviewed the Aultman Experience education. I am responsible and accountable for the information, and I will apply this knowledge to provide the Aultman Experience in all of my interactions during my Student Experience.

I have received and reviewed the Student Experience Educational Packet. I am responsible and accountable for the information in the Student Experience Educational Packet.

Draw or Type

I understand this is a legal representation of my signature. Clear

Internship Application

Internship Application

GENERAL INFORMATION

SCHOOL/COLLEGE/UNIVERSITY INFORMATION

INTERNSHIP INFORMATION

INTERNSHIP REQUIREMENTS

ATTESTATIONS