Please let us know your availability by selecting the days and times you are available to volunteer for the opportunity you are applying. To select multiple times, select your first option and then place the cursor back in dropdown menu the field to continue selecting other options.

Please provide a personal or professional reference. If providing a personal reference, this should be someone other than a family member.

                                                                                    EMPLOYMENT CANDIDATE 
                                 OBSERVATION/SHADOWING AND CONFIDENTIALITY AGREEMENT

 

The undersigned is a prospective candidate or volunteer (“Candidate” or “Volunteer”) for a position at Premier Pediatric Therapy Source, Inc. (PPTS). As part of the selection process for the position and/or volunteer opportunity, the Candidate or Volunteer will be visiting PPTS and observing various employees and activities that may occur across multiple settings including the clinic, telehealth, family homes, preschools/daycares and/or the community. The Candidate/Volunteer acknowledges that the execution and delivery of this Observation/Shadowing and Confidentiality Agreement is required in order to participate in any pre-employment visits or volunteer opportunities at Premier Pediatric Therapy Source, Inc.
 

Candidate Agreement:

I understand that I may come in contact with information during my visit(s) at Premier Pediatric Therapy Source. This information may include, but is not limited to, information on patients, their condition, services received, insurance plans, employees, students and financial and business operations (collectively referred to as “Confidential Information”). Some of this information is made confidential by law (such as “protected health information” or “PHI” under the federal Health Insurance Portability and Accountability Act (HIPAA)) or by PPTS policies. Confidential Information may be in any form, e.g., written, electronic, oral, audio, overheard or observed. I further understand that violations of PPTS privacy policies and procedures may result in civil and/or criminal liabilities and penalties.

 

As an observer, I agree to the following:

• I am aware of and assume the risks involved with the shadowing/observing experience and understand that any costs I incur as a result of participation will be my responsibility
• I agree to comply with all PPTS policies and procedures and all PPTS employee instructions
• I will not provide direct therapeutic care, including but not limited to patient care, clinical care or documentation in the record. I understand that I must be accompanied by a PPTS team member when observing patient care activities and I will have no independent access to patients or patient records.
• I will review the applicable PPTS Notice of Privacy Practices and company policies on confidentiality and privacy, including any policies that are specific to the entity, setting and/or department in which I am visiting or observing.
• I will not, at any time, disclose to others, or use or copy, without the prior written consent of PPTS, any confidential or proprietary information of PPTS, or any PHI on any patients.
• I will not disclose Confidential Information to other patients, friends, relatives, co-workers, businesses or anyone else, except as required by law and will not post or discuss Confidential Information, including pictures and/or videos on any social media sites (e.g. Facebook, Instagram, Twitter, etc.).
• I will not access, maintain or transmit Confidential Information on any unencrypted portable electronic devices (e.g. Blackberries, Androids, iPhones, iPads, etc.) and agree to use such devices in accordance with PPTS policies only.
• I will protect the confidentiality of all Confidential Information, including PHI, while at PPTS and after I leave Premier Pediatric Therapy Source, Inc.

All Confidential Information remains the property of Premier Pediatric Therapy Source, Inc. and may not be removed or kept by me when I leave PPTS except as permitted by PPTS policies or specific agreements or arrangements applicable to my situation.

 

I understand a copy of this signed agreement will be kept in my pre-employment or volunteer file and that any violation of this agreement may forfeit any opportunity for me to be considered for a position at PPTS either now or in the future. If I am hired by Premier Pediatric Therapy Source, Inc. and it is later learned that I violated this agreement, I may be subject to disciplinary action, up to and including discharge, under applicable human resources policies.

 

This Agreement is valid for ninety days from the date of execution; however, the obligations set forth in this Agreement survive the expiration date.

 

My signature below indicates that I have read and understand this agreement and agree to comply with its terms. I further release Premier Pediatric Therapy Source, Inc. from all liability claims for any loss or injury arising from this experience and/or any negligent or wrongful acts or omissions of the employees or agents of Premier Pediatric Therapy Source, Inc.

I acknowledge and consent to the following terms and conditions:

 

1.     Nature of Volunteer Work:  I understand that as a volunteer, I may be involved in various tasks, which may include but are not limited to assisting therapists, interacting with children and their families, organizing materials, participating in administrative tasks and maintaining a clean and safe environment.

2.     Non-Disclosure:  I agree that at all times while volunteering at Premier Pediatric Therapy Source, Inc., and following the end of the volunteer opportunity, to maintain and not to disclose to any third party, any non-public, confidential or proprietary information relating to the business or financial practices, operations, contracts, instruction materials, education or exercise programs, marketing plans or materials, pricing, and/or any other confidential information or trade secrets of Premier Pediatric Therapy Source, Inc., including the terms of consent, whether or not labeled as “Confidential” and regardless of the method of transmission or the media in which the same is stored or recorded (“Confidential Information”).

3.     Code of Conduct:  I will conduct myself in a professional and respectful manner at all times while volunteering for Premier Pediatric Therapy Source, inc. I will follow the Practice’s policies and procedures, treat all individuals with respect and maintain a positive and supportive environment for children, families and staff.

4.     Safety and Health: I understand that I must prioritize safety and adhere to all safety protocols and guideline provided by Premier Pediatric Therapy Source, Inc. I will promptly report any hazards, accidents or injuries to the appropriate staff members.

5.     Liability Release:  I release and hold harmless Premier Pediatric Therapy Source, Inc., its employees, contractors and agents from any liability for any injuries, damages or losses that may occur during my volunteer work.

6.     Medical Information: I confirm that I am physically and mentally capable of performing the volunteer duties assigned to me. I will promptly notify the Practice of any medical conditions, disabilities or allergies that may affect my ability to perform my duties safely.

7.     Background Checks: I understand that Premier Pediatric Therapy Source will require a background check as part of the volunteer screening process. I understand I have the right to withhold my consent to have a background check conducted however, in doing so I understand my application will not be processed. By signing this consent, I authorize Premier Pediatric Therapy Source to conduct a background check to ensure the safety and well-being of its clients and staff.

8.     Photo and Video Release:  I grant Premier Pediatric Therapy Source, Inc. permission to use any photographs or videos taken of me during my volunteer activities for promotional or educational purposes. This may include but is not limited to printed material, the Practice website, social media, email marketing and/or other advertising.

9.  Duration of Volunteer Service:  This consent form is valid for the duration of my volunteer service at Premier Pediatric Therapy Source. Either party may terminate the volunteer relationship at any time with prior notice.

 

By signing below, I acknowledge that I have thoroughly read and understand this consent in its entirety and agree to abide by the terms and conditions outlined herein.