Your application is reviewed by qualified hospital staff, and is our first experience with you. For this reason, it is important to be thorough and accurate in your answers. Please use proper capitalization and punctuation.

In the application, we use extended response questions to best evaluate comprehension of the materials you need to know before coming into the hospital. Each question requires a response that indicates you've read and understand the material.

Follow these guidelines to ensure your answers are complete and adequate.

• Use your own words - copying and pasting answers is not acceptable.
• Answer all questions - your application will not be processed unless it is complete.
• Submit a full answer rather than a one-word answer or a list when a summary or description is required.

This information will be kept confidential and used only in conjunction with this program.

Salem Health Mission: To improve the health and the well-being of the people and the communities we serve.

Salem Health Vision: Exceptional Experience Every Time

Salem Health Values: Excellence, Accountability, Integrity, Caring, Teamwork

Healthcare Infection Prevention – Best practices for preventing healthcare associated infections (HAI’s) are related to hand hygiene. The single most important factor for preventing the spread of infection is proper hand hygiene to protect our patients and ourselves.

The Joint Commission requires hospital compliance with the World Healthcare Organization (WHO) and the Center for Disease Control (CDC).

All staff including visitors should wash or decontaminate BEFORE and AFTER each patient visit. Hand hygiene should also occur after gloves are removed.

Safety is responsible for managing three areas of the Environment of Care; Safety and Health, Fire Prevention, and Hazardous Materials & Waste. Keeping the hospital in compliance with DEQ, OSHA, EPA and DOT rules is one major component of our safety management program.

Security can be contacted by calling from a Salem Hospital phone to 40311 (routine) or 40911(emergency calls).

Violence Salem Health has a “Zero Tolerance” policy against violence in the workplace. Violence may be in the form of physical altercations as well as verbal (i.e. threats)

All violence is to be reported via;
       – Patient Safety Alert (PSA) – Security – House Supervisor

Visitors do not have the right to visit, they have the privilege which can be revoked for specific reasons (i.e. infection control issues, interference with care, court orders, disruptive behavior, etc. CMS 428.13).

Emergency Codes Each observer will be exposed to the code system and should remain with the person they have been assigned in the case of a code. Said staff person will provide observer additional information as needed.

By clicking the OK button I acknowledge that I have read and understand everything in this window.

Read the following before completing your application.

The mission of Salem Health is to improve the health and well-being of the people and community we serve.

Emergency preparedness: All approved observers will be given a name badge with our emergency codes on the back for the career exploration experience. Should a code be called observers are expected to follow the directions of the healthcare provider. For example, a code blue in the room requires the observer to follow the direction of the person one is observing. In this instance the health care provider will ask the observer to step to the back of the room or out of the room depending on the situation.

Prevent the spread of germs: Our policy is that upon entering and exiting a patient room everyone must use the hand sanitizers located on the outside of door.

Observation experience – This experience is an opportunity for to view a healthcare professional in their work setting. The observer will be able to ask question and view the health care provider’s work. Physical contact and any direct care (i.e. pushing a wheelchair, helping a patient stand up, taking patient blood pressure, etc.) with patients, is not permitted as part of this experience.

First Name

Middle Name

Last Name

Address Line 1

City

State

-- Select State -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

Home Phone

Mobile Phone

Email Address

Date of Birth

Gender

-- Select Gender -- Female Male

Emergency Contact

Emergency Contact Phone

Career Goals

What healthcare career or careers are you interested in?

School or Organization Information

cep_Participant

What are your academic goals? What degrees or training would you like to complete?

Currently enrolled in an academic program?

School

-- Select School -- 21st Century Community Schoolhouse ABC Computer Training Center Amity High School Apollo College Argosy University AT Still University Azusa Pacific Banks High School Barbara Roberts High school Belmont University Benedictine University Binghamton University Blanchet High School Brigham Young University Burney Jr Sr High California College for Health Sciences California State University Carrington College Cascade High School CCC CCC Business CCC MOA CCC Nursing CCC Pharmacy Tech CCC Pre-Nursing Central High School Central Oregon Community College Chamberlain University Clackamas Community College Clark College Colorado State University Colton High School Computer Skills Plus Concorde Career Institute Concordia University Corban College Creighton University Dallas High School Dayton High School Des Moines University DeVry Downtown Learning Center Drexel University Duke University Early College HS @ CCC Eastern Mennonite University Eastern Oregon University Emory University Emoz University Everest College Excelsior College Falls City High School Florida College of Health Sciences Frontier School of Nursing George Fox University Georgetown University Gervais High School Gonzaga University Gordon College Grand Canyon University Health & Educational Consultants Home Schooled Idaho State University Independence University Independent Indiana State University Institute of Technology Iowa State University Jackson Community College Jefferson High School JFK High School Judson Middle School Lake Oswego Lane Community College Lebanon High School Leslie Middle School Lewis & Clark College Liberty University Linfield College Linn-Benton Livingstone Adventist Academy Loyola University-New Orleans Macalester Marylhurst University McGill University McKay High School McMinnville High School McNary High School Mid Willamette valley Dietetic Internship Midwestern University Morrison Charter School Mt. Hood Community College Multnomah Bible College NC State University Nestucca High School Newberg High School NIFA No Affiliation Agreement North Park Theological Seminary North Salem High School North Seattle Comm. College Northwest Institute for Healthcare Training Nurse Re-Entry Program OHSU (OreHealthScienUniv) Oklahoma Christian College Oregon Institute of Technology Oregon State Police Oregon State Police Oregon State University Other Pacific Lutheran University Pacific Union College Pacific University PCC - Breckenridge School of Nursing Perrydale High School Philomath High School Phlebotomy Plus Pioneer Pacific College Portland Comm College Portland State University Regis High School Rogue Community College Sacred Heart University Saint Joseph's College Salem Academy Samaritan Health Services Samuel Merritt College San Diego State University Sanford Brown Santiam High School Scio High School Seattle Pacific University Sheridan High School Silverton High School SK Online South Fork (Fl )High School South Salem High School Southeast Community College Southern Oregon University Southern Utah University Spokane Community College Spokane Falls Community College Sprague High School Springfield High School St. Luke St. Paul High School Stanford University Stayton High School Stayton Middle School Stephens Middle School Sumner College Sweet Home Texas Women's University The University of Alabama UC Davis UC San Diego Ultimate Medical Academy University at Buffalo University of California San Diego University of Cincinnati University of Colorado University of Dayton University of Hawaii University of Idaho University of Montana University of North Dakota University of Northern Colorado University of Oregon University of Pacific University of Phoenix University of Portland University of Puget Sound University of Redlands University of Saint Mary University of Virginia University of Washington University of Wisconsin La Crosse University of Wisconsin-OshKosh University of Wuerzburg Valley Medical College Valley Medical College Wake Forest University Walden University Walker Middle School Walla Walla College Warner Pacific Washington State University WEB WOC Weber State University WebWOC Nursing Education Program Wells College West Salem High School Western Baptist College (Corban) Western Governors University Western Mennonite School Western Oregon University Western University Westmont College Whiteaker Middle School Whitman College Whitworth College Willamette ESD Willamette University Willamette Valley Christian Willamina High School Wilsonville High School Woodburn High School WOU/OIT WVBCS Yamhill-Carlton High School

Graduation Month

Graduation Year

-- Select Month -- January February March April May June July August September October November December

GPA

Is the CEP Experience a required activity for one of your current Courses?

Name of Course

Advisor

How Many Hours are You Required to Participate?

How Many of Those Hours Need to be Completed at this Location?

Scheduling

cep_Participant

First Date Available

Your availablity

In the hours available column enter the time you are available on that weekday. For example: 08:00 - 15:00 or 8AM to 3PM

Day of Week	Hours Available
Monday
Tuesday
Wednesday
Thursday
Friday

Application Questions

cep_Participant

Question 1
What is confidentiality? Why it is important for you to keep patient information confidential at all times?

Question 2
What is the best way to prevent the spread of germs at the hospital? What steps must you follow to avoid spreading germs during your job shadow?

Question 3
List up to three areas of the hospital where you would like to job shadow. List your first, second, and third choices. These selections will determine where you are scheduled to job shadow.

Question 4
What should you do if there is an emergency situation in the area at the hospital where you are job shadowing?

Question 5
Why do you want this experience? Why should we provide this experience for you?

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