Morristown Medical Center - Application for Mentorship Program · Payment is through...

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Center for Internships and Career Development - Sycamore Cottage - 973-408-3593 - fax 973-408-3535

Review each of the following sections of the Application and complete all documentation to apply for the

MMC Mentorship Program:

1. Program Guidelines

2. Deadlines

3. General Information

4. Application Process

5. Instructions for Application Forms

6. Form – Student Coursework Background (top of form – page 5)

7. Form – Non-Clinical Student Information Sheet (bottom of form – page 5)

8. Instructions for Medical Documentation

9. Form – Immunization / Training Record

10. Form – Hepatitis B Vaccine Waiver

11. Form - Mentor Program Agreement

12. Form(2 sheets) - Mentor Program Essays

13. Online transaction: Request for Background Check

14. Checklist

Program Guidelines Required:

Minimum GPA of 3.0 within the sciences (at time of application)

At least 2 semesters of a Math or Science course

Most recent copy (can be unofficial copy) of transcript (Attach to application)

Recommended:

Complete the following courses before participating in Mentorship Program:

BIOL 256 Vertebrate Anatomy & Physiology I

BIOL 258 Vertebrate Anatomy & Physiology II

Morristown Medical Center - Application for Mentorship Program

Application Deadlines

Completed applications will be submitted to the hospital on a first-come, first-served basis – get your

application in as early as possible. Openings are limited – the hospital makes the final decision on the

number of openings for each term.

The application forms and medical documentation MUST be submitted by the following deadlines.

Semester

FIRST day Applications

will be accepted

LAST day Applications

will be accepted

Fall 2018

April 15, 2019

August 12, 2019

Spring 2019

October 15, 2019

November 15, 2019

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Program Guidelines (Continued)

There are a limited number of the Mentorship positions available for the fall and spring terms. MMC

makes this determination from term to term.

Mentorship positions will be filled in the order that completed applications are received by the Center for

Internships and Career Development according to the deadline dates listed above.

Only completed applications with all medical documentation will be accepted and forwarded to Morristown

Medical Center. NO EXCEPTIONS!

_______________________________________________________________________________________

General Information ORIENTATION: Orientation is MANDATORY and will count toward your minimum hourly requirement. Orientation sessions

are generally scheduled for as close to the beginning of the term as possible. You will be notified of the

exact date upon acceptance to the program.

Orientation will take approximately one to two hours. It consists of an overview of the mentor program, the

ongoing research studies, and a tour of the Emergency Department. You will also be given the Hospital

Orientation packet to complete at home prior to starting the program.

HOURLY AND OTHER REQUIREMENTS: After you have completed Orientation, you will be eligible to sign up for your first shift. Each shift is a

minimum of 4 hours. Please complete the green time cards and submit them to document your hours. All

students will be required to work a minimum of 70 and possibly up to 75 hours during the course of the

internship.

In addition to the hour requirements on site, there will be other responsibilities such as those listed on the

Student Learning Contract, which must be signed and submitted to the Center for Internships and Career

Development prior to the start of the internship.

DRESS CODE: Your Drew University ID must be worn and visible at all times.

While in the ED, you will need to wear appropriate attire since this shows respect for the patients, who may

view you as being part of the hospital staff.

Please note: You cannot wear sneakers, shorts, tank tops, ripped pants, jeans and/or open-toed shoes,

and no leggings.

MEN: - a neat shirt and slacks

WOMEN: - a blouse and KNEE-LENGTH skirt or pants, or a dress are appropriate. PLEASE BE CAREFUL

THAT YOUR CLOTHING IS NOT TOO TIGHT OR REVEALING!

You will be required to wear a short lab coat. This will not only identify you (along with your school

identification badge) as part of the hospital personnel, but will also protect your clothing from any

inadvertent spills. You must supply your own lab coat.

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General Information (Continued)

BACKGROUND CHECK: The student MUST submit a request for a Background Check and provide payment, when applying for this

program. Please see page 13 of this application for information on submitting this request online.

Payment is through VISA/Mastercard in the amount of $84.00.

Acceptance into the Program is contingent on successful clearance. Since the process takes

approximately 4 weeks, please submit the online request immediately after your application has been

approved by the Center for Internships and Career Development. REIMBURSEMENT FOR THIS EXPENSE

IS AVAILABLE UPON REQUEST. PLEASE EMAIL [email protected] FOR INFORMATION!

Please contact Janet Cillo (908-879-4816) with any questions regarding the background check.

FOR MORE INFORMATION: Center for Internships and Career Development

Jenn Islam, Launch Catalyst, [email protected]

Dunstanette Macauley-Dukuly, Launch Catalyst, [email protected]

__________________________________________________________________________________________

Application Process To apply for the MMC Mentorship Program, the following Application Forms and Medical Documentation

must be completed and submitted to the Center for Internships and Career Development by the deadline

dates listed above. They include:

1. Student Coursework Background (top of form – page 5)

2. Non-Clinical Student Information Sheet – bottom of form on page 5 (including most recent copy of

transcript – can be unofficial copy)

3. Immunization/Training Record (including doctor records of immunizations and the two TB tests,

and the required doctor’s note)

4. Hepatitis B Vaccination Waiver Form

5. Mentor Program Agreement

6. Mentor Program Essays Form

7. Online Background Check Request (there is no form sent to the Center for Internships and Career

Development for this)

8. Checklist

mailto:[email protected]



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Instructions for Application Forms

STUDENT COURSEWORK BACKGROUND

NON-CLINICAL STUDENT INFORMATION SHEET

Please fill out the top portions of form where required.

IMMUNIZATION/TRAINING RECORD

Please fill out the top section of the form, including Name, Social Security Number, Home

Address, and Date of Birth.

Immunization – Please provide dates for all the immunizations listed on this form

and attach a copy of your immunization records from your physician’s office.

Training – This section will be completed by MMC personnel.

Infection Control - This section will be completed by MMC personnel.

You must sign and print name on bottom of page, as indicated. The physician providing

verification of your immunization status must also sign this form.

HEPATITIS B VACCINATION WAIVER FORM

This form must be completed if you do not have current immunity to Hepatitis B, evidenced

either by 3 shot series or a positive Hepatitis Surface Antibody blood test.

MENTOR PROGRAM AGREEMENT

Please complete and sign.

MENTOR PROGRAM ESSAYS

Please complete all essays (three to four sentences per question).

REQUEST FOR BACKGROUND CHECK

Please follow the instructions on page 13 of this application to submit your background

check request online to TABB Inc.

There is no form to print or fax/mail/deliver to any office. The entire background

check process is done online.

Reimbursement for this expense is available upon request, if qualified. Contact

[email protected] for more information.

CHECKLIST

Please indicate items that are completed and attached.


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AHS Department Rotation Supervisor ROTATION DATES Start: End:

STUDENT COURSEWORK BACKGROUND

GPA in the sciences (at time of application): _________ Grad Year: _______

Have you taken the recommended courses BIOL 256 & 258? _____ Yes _____ No

Have you taken at least 2 semesters of Math / Science Course work? ___Y ___N

During which semester do you intend to be in the mentor program?

SPRING FALL Year __________

Non-Clinical Student Information Sheet Please PRINT legibly and complete all sections of this form.

NAME: Last First MI Social Security #

Date of Birth (MM/DD/YYYY) Personal E-Mail Address Cell Number

Home Address

Emergency Contact Name Phone#

EDUCATION School/University Name Current Year

Drew University Major Program Advisor

School Address

36 Madison Avenue Madison, NJ 07940

ISS Domain Access Security Question (CHOOSE ONE TO ANSWER) What is the name of your favorite book/magazine? favoriteboobook/magazine?ine?

What is the make and model of your first car?

AHS ROTATION INFORMATION (To be completed by MMC personnel)

AHS DEPARTMENT APPROVAL (To be completed by MMC personnel)

Name Title Date

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Instructions for Medical Documentation

1. TB Tests

It is mandatory that all students entering into the Mentor Program have 2 negative TB

tests within the year prior to starting the program.

If you have NOT had two negative TB tests within the last 12 months, you ARE REQUIRED

to have the two step process done. This consists of two negative tests completed, given

within 1-3 weeks of each other. Testing can be done at Drew Health Services office

(x3413) for a small fee or contact your primary physician to have this completed.

If your TB test is POSITIVE, you must provide a Chest X-Ray. The Chest X-Ray must be

dated within 3 months prior to starting the program.

2. Measles, Mumps and Rebella

You will need proof of immunity against measles, mumps, and rubella. Please also attach

this record to your Application.

3. Varicella Titer

Proof of two doses varicella vaccine, 4-8 weeks apart

4. Hepatitis B

Although we do not absolutely require proof of immunity against Hepatitis B, we strongly

recommend it because exposure to patients in an Emergency Department can, in rare

instances, lead to transmission of Hepatitis B.

Proof of immunity would include either:

3 shot immunization series and/or

proof of serologic immunity

Failing proof of immunity, you will need to sign a waiver (attached) releasing the hospital

from responsibility should you contract Hepatitis B while you are in the Emergency

Department.

Please note: The questions about immunizations for other diseases should be completed,

but are not mandatory for your acceptance into the program.

5. Physical

With your Application, please enclose a letter from your physician stating that you “are

generally in good health and have no communicable diseases”. For example, a doctor’s

note for John Doe would state: “John is generally in good health and has no communicable

diseases”. This documentation must be articulated verbatim and must be dated no more

than 3 months prior to starting the program.

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(Please provide dates for all immunizations on this form and attach a copy of your immunization records

from your physician’s office. Please also be sure to include the doctor’s note with the required statement

about your health – see “physical” on page 7 for complete information about this)

ATLANTIC HEALTH SYSTEM

Immunization/Training Record for Non-Atlantic Health Student, Agency, or Contract Personnel

Name: Social Security #: DOB: / _/

Address:

Name of School/Agency: Drew University

Supervisor (if applicable): Jenn Islam – Center for Internships and Career Development

IMMUNIZATION YES/DATES NO

Hepatitis B: (Must have one of the following)

A. Proof of having all three doses of the Hepatitis B Vaccine.

B. Documentation of a positive Hepatitis Surface Antibody (HBsAb)

C. Vaccine Waiver Form: (see attached)

Rubeola (Measles):

A. Rubeola Titer – demonstrate immunity: Immune:

Rubella (German Measles): applies to all

A. Rubella Titer– demonstrate immunity: Immune:

Mumps: Must have one of the following A. Proof of two doses of live mumps (or MMR) vaccine after his/her first

birthday B. Mumps Titer: – demonstrate immunity: Immune:

Varicella Titer: (Must have one of the following)

A. Proof of two doses of varicella vaccine, 4-8 weeks apart

B. Varicella Titer: – demonstrate immunity: Immune:

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IMMUNIZATION / TRAINING RECORD (Continued)

Tuberculosis Skin Testing (TST)*:

A. No signs and symptoms of active TB and Two-step TST (2 Mantoux

tests given within 1-3 weeks of each other) within the past 12 months, OR

B. Single TST if one documented negative TST within the past 12 month, OR

C. Prior documentation of negative results of 2 Mantoux tests performed within 12 months preceding work at an Atlantic Health System facility.

D. Adequate two-step TST followed by annual testing. If positive TST :

E. Documentation of test result & negative chest X-ray in the past 6 months, &.

F. Documentation that individual does not have active tuberculosis infection.

G. If latent tuberculosis infection, documentation of adequate treatment if individual was treated.

If evaluated with blood assay for Mycobacterium tuberculosis (BAMT), those results should be submitted instead of TST.

TRAINING: (This section to be completed by MMC personnel) Hazard Communication/Right to Know:

A. Awareness of biological hazards in healthcare institutions.

INFECTION CONTROL

(This section to be completed by MMC personnel)

A. Understands epidemiology & symptoms of

bloodborne (Hepatitis B & C & HIV) diseases, tuberculosis, & influenza. B. Understands modes of transmission of bloodborne pathogens,

tuberculosis, & influenza & similar infections. C. Understands isolation precautions & the appropriate use of personal

protective equipment.

Occupational Injuries & Illnesses: All schools or agencies must have a prior arrangement with their students/personnel of what to do in the event of an occupational injury or illnesses, including bloodborne pathogen exposures.

Contagious Diseases:

This individual completing this form is free from contagious disease. Yes No

===================================================================

Signature of student/agency/contract personnel Date

Signature of health practitioner providing immunization documentation

(REQUIRED)

Name & Title of Atlantic Health System employee who reviewed record

Signature of Atlantic Health System employee who reviewed record Date

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HEPATITIS B VACCINATION WAIVER FORM (This Form must be completed if you do not have current immunity to Hepatitis B, evidenced

either by 3 shot series or a positive Hepatitis Surface Antibody blood test.)

I, __________________________________ understand that due to my occupational exposure to blood or other

potentially infectious materials. I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been advised

to be vaccinated at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring

hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially

infectious material and I want to be vaccinated with hepatitis B vaccine, I will arrange to receive the vaccination

myself.

__________________ _________________________________________

Date Signature

____________________________ _________________________________________

Guardian or Parent Witness

(If applicable)

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MENTOR PROGRAM AGREEMENT

Have you ever been convicted of a crime, including misdemeanors and summary offenses? _____ No _____ Yes If yes, describe fully the criminal conviction(s), listing the nature of offense, and your rehabilitation since the conviction(s). (A conviction record will not necessarily be a bar to appointment). _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ PATIENT PRIVACY AND CONFIDENTIALITY Patient confidentiality is a major focus of concern in the hospital. You need to know that you:

Should not discuss patient condition or diagnosis in elevators, the cafeteria or other public areas;

Should not use elevators that are occupied by patients on stretchers- this compromises patients dignity and privacy;

Should not transport equipment/charts bearing patients names in elevators occupied by visitors;

Should keep charts and records bearing patients names out of public view;

Should close curtains and doors;

Should knock on doors or announce yourself prior to entering a patient’s room. I UNDERSTAND THAT, IF ACCEPTED AS A MENTOR PROGRAM PARTICIPANT I will offer my services with a clear understanding there will be no monetary compensation. I will readily accept training and supervision by staff. I will observe all hospital regulations, and will not divulge any confidential information that I shall see or hear during my Mentor Program participation at Morristown Medical Center. I understand that any mistreatment, omission, or misleading information given in my application or interview or in connection with other Hospital records may result in the rejection of my application, the withdrawal of any offer or my dismissal after application. Signature:____________________________________________ Date:____________________________________

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MENTOR PROGRAM ESSAYS PLEASE ANSWER THE FOLLOWING (3 or 4 sentences per question):

What do you hope to achieve from the mentor program?

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

What are your career goals?

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

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MENTOR PROGRAM ESSAYS (Continued)

What are some of your hobbies and interests?

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Please list all previous hospital experience, if any.

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

____________________________________________________________________________

Career Interest:

Physician (MD or DO) Nurse Physician Assistant Other: ______________

Specialty of Interest (check all that apply): Emergency Medicine Internal Medicine

Neurology Pediatrics Radiology Anesthesiology Surgery

Cardiology Sports Medicine OB/GYN Family Practice Psychiatric

Dermatology Dental Other: __________________________________

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TABB INC.HUMAN RESOURCE SERVICES Student JCACHO Compliance SERVICE IS OUR NUMBER ONE PRIORITY

PO BOX 10; 555 E. Main St., Chester, NJ 07930; Phone: (908) 879-4816; FAX (908) 879-8675; www.tabb.net

Atlantic Health System Student Background Report

To insure the safety of medical patients, all students, volunteers and interns who will come in contact with patients during

the course of your training must undergo a criminal record search and/or a drug screening. Atlantic Health System has

chosen TABB INC., a licensed private investigation agency specializing in pre-employment background investigations for

the medical community, to conduct the criminal checks for their students.

Please visit the following link: https://www.backgroundinvestigationsbytabb.com/studentindex.aspx - and then click on:

“ORDER A BACKGROUND INVESTIGATION”

By following this process, you are creating your account with TABB. Please answer all questions and provide accurate

credit card information. Any area left unanswered or entered incorrectly will delay processing your background check.

You are creating an account with TABB that will allow you to view the progress of your background investigation and

order additional background checks should the need arise. You will receive emails from TABB INC. advising you of

status of your account and report. Additionally, results of your background investigation will be available to you for the

next five years by simply logging into your account with TABB INC. at the above website. Remember, once an account

has been created, your email address is your username.

Choose the option from the drop down menu for: Atlantic Health Systems – Student Report

The background investigation that will be conducted is similar to those conducted by hospitals for employment purposes

and/or student-intern searches and will include a database search which will develop all addresses where you have lived as

an adult and a criminal record search at all addresses where your have lived past or present, a Database Search, Statewide

and/or County Searches at all address past and present, a Promise Gavel Search, GSA Excluded Parties List Research and

a U.S. Department of Health & Human Services Office of Inspector General (OIG) Search.

Send Report to Additional Email Addresses: To ensure the Medical Center receives a copy of the report, please be

sure to include the AHS contact person’s e-mail address in the box provided during the ordering process.

Contact: [email protected] The system will automatically send the report to your email address and the contact person at the organization or health

care facility you selected once the report has been completed.

The criminal record check will not be processed unless valid credit card information is provided. To avoid delays, please

insure that accurate information is provided. Your VISA or Mastercard will be billed for this report and will appear as

TABB INC. on your credit card statement. The report price for this search will be $84.00. A completed copy of your

report will be sent to Atlantic Health Systems and you will receive a completed copy of the report. The results of this

search, for New Jersey residents, may take approximately ten or fourteen businesses days to be returned due to delays with

the New Jersey State Police.

If you should have any questions regarding this process, please contact: Janet Cillo College Account Manager TABB INC. 908-879-4816 [email protected]

http://www.tabb.net/

https://www.backgroundinvestigationsbytabb.com/studentindex.aspx


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Checklist for MMC Mentorship Program All documents below must be submitted to the Center for Internships and Career Development by the deadline.

(Incomplete Applications will not be submitted to MMC.)

Student Name: _________________________________________ Semester: _______ Year: _______

Completed

Career Center

Receipt

MMC

Approval

MEDICAL DOCUMENTATION: You MUST provide dates for all immunizations on the enclosed

form AND attach a copy of your immunization records from your

physician’s office.

2 Negative TB Tests (within past 12 months)

If you have not had two negative TB tests within last 12

months, you are required to take 2-step process – 2

negative TB tests completed, with a minimum of two

weeks between the first test and second test.

If TB test is positive, you must provide a Chest X-Ray.

The Chest X-Ray must be dated within 3 months prior

to starting the program.

1st _____

2nd

_____

_______

1st _____

2nd

_____

_______

1st _____

2nd

_____

______

Measles, Mumps and Rubella (Proof of Immunity)

Hepatitis B

Either: Proof of Immunity (3-shot immunization series

and/or proof of serologic immunity.

Or: Sign a waiver releasing the hospital from

responsibility should you contact Hepatitis B.

OR

_________

OR

________

OR

________

Physical - Letter from physician stating you “are

generally in good health and have no communicable

diseases”. Document must be articulated verbatim and

dated within 3 months of the start of the program.

A COPY OF YOUR MOST RECENT TRANSCRIPT MUST

BE ATTACHED (with a 3.0 GPA in the sciences – official

transcript not required)

FORMS: Student Coursework Background/Non-Clinical

Student Information Sheet

Immunization/Training Record

Hepatitis B Vaccination Waiver Form (optional)

Mentor Program Agreement

Mentor Program Essays

Request for Background Check – Online submission

of request to TABB Inc. with $84 payment.

Reimbursement for this expense is available upon request, if

qualified. Contact the Career Center for more information.

We are looking forward to you joining us and hope that this experience will be rewarding for you.

Morristown Medical Center - Application for Mentorship Program · Payment is through...

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