Faculty Shadowing Guidelines and Form * designates required fields You are requesting to shadow a Department of Anesthesiology Faculty member. If this is not your intent, please contact the appropriate department you wish to shadow. Do not submit this form until you have all the elements listed below. You will not be able to come back to this form after it has been submitted.Name * Required First Last Email * Required Enter Email Confirm Email Individuals allowed into patient care areas, including the operating suite, is defined as meeting at least ONE of the following criteria. Please mark the applicable responses below.Hold current licensure or certification as a medical or health care professional * Required Yes No Are currently enrolled in a medical or health care professional degree program, or affiliated with a UAMS student health care program * Required Yes No Are a representative through employment with a company or agency that holds current interest in a specific patient care activity (sales rep) * Required Yes No Are you a UAMS employee or student? * Required Yes No You must follow all THREE steps below and submit the requested documentation for your application be considered complete and to be scheduled for review. Please allow 1-2 weeks after your submission to receive notification of an approved shadowing date. Sending all documents promptly and together will help expedite review. Once all of this information has been received (and your requested date has been approved) you will receive an email from Veronica Ussery with confirmation details for your shadowing date.If you are a non-UAMS employee/student (and meet one or more of the above criteria) please submit the documentation below for your shadowing application to be scheduled. Complete and sign these two forms: Request to Shadow and Confidentiality Statement. Be sure to provide several date options. Send a copy of your immunizations, along with flu shot documentation if during flu season, to UAMS Student and Employee Health with a message that you are requesting to shadow a CRNA in the operating room. They will send you an email once they have confirmed that you are compliant with UAMS immunization requirements. Please do NOT submit your immunization records here. Just save the confirmation email from UAMS Student and Employee Health as a PDF or screenshot and upload it with your other documents below. UAMS HIPAA Required Privacy & Security training module – below is the link to this module. This module cannot be completed on a mobile device such as an iPad, cell phone or tablet. It will work on those but it will not allow you to submit the completion page at the end that gives you credit for this training module. Please make sure that your pop-up blocker is disabled. Please contact the UAMS HIPAA Office at 501-603-1379 for any assistance or questions. Once you have completed this module, upload the confirmation page as a PDF or screenshot in the appropriate slot below. Access the HIPAA training module You must follow all THREE steps below and submit the requested documentation for your application be considered complete and to be scheduled for review. Please allow 1-2 weeks after your submission to receive notification of an approved shadowing date. Sending all documents promptly and together will help expedite review. Once all of this information has been received (and your requested date has been approved) you will receive an email from Veronica Ussery with confirmation details for your shadowing date.If you are a UAMS employee/student (and meet one or more of the above criteria) please submit the documentation below for your shadowing application to be scheduled. Complete and sign these two forms: Request to Shadow and Confidentiality Statement. Be sure to provide several date options. Send a copy of your immunizations, along with flu shot documentation if during flu season, to UAMS Student and Employee Health with a message that you are requesting to shadow a CRNA in the operating room. They will send you an email once they have confirmed that you are compliant with UAMS immunization requirements. Please do NOT submit your immunization records here. Just save the confirmation email from UAMS Student and Employee Health as a PDF or screenshot and upload it with your other documents below. UAMS HIPAA Required Privacy & Security training module – Please log into MyCompass to retrieve your HIPAA compliance certificate. Print it as a PDF or take a screen shot. Please contact the UAMS HIPAA Office at 501-603-1379 for any assistance or questions. Upload Files Part 1 * RequiredUpload your signed Request to Shadow form here.Max. file size: 15 MB.Upload Files Part 2 * RequiredUpload your signed Confidentiality Statement form here.Max. file size: 15 MB.Upload Files Part 3A - Immunization Documentation * RequiredUpload a PDF or screenshot of your email from Student and Employee Health here.Max. file size: 15 MB.Upload Files Part 3B - Flu Shot DocumentationUpload a PDF or screenshot of your email from Student and Employee Health here. Note: this is only required during flu season.Max. file size: 15 MB.Upload Files Part 4 * RequiredUpload a PDF or screenshot of your HIPAA training confirmation page here.Max. file size: 15 MB.Do not submit this form until you have all the elements above. You will not be able to come back to this form after it has been submitted.EmailThis field is for validation purposes and should be left unchanged.
