Default Page Student Placement Application Name This field is required This field needs to be a valid value Street This field is required This field needs to be a valid value City This field is required This field needs to be a valid value State Choose One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Maryland Massachusetts Michigan Minnesota Mississippi Missouri Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming This field is required Zip This field is required This field needs to be a valid value Phone This field is required This field needs to be a valid value Email This field is required This field needs to be a valid value Home address (if different than above) This field is required This field needs to be a valid value City This field is required This field needs to be a valid value State Choose One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Maryland Massachusetts Michigan Minnesota Mississippi Missouri Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming This field is required Zip This field is required This field needs to be a valid value School name This field is required This field needs to be a valid value School address This field is required This field needs to be a valid value City This field is required This field needs to be a valid value State Choose One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Maryland Massachusetts Michigan Minnesota Mississippi Missouri Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming This field is required Zip This field is required This field needs to be a valid value Program name This field is required This field needs to be a valid value School advisor/counselor This field is required This field needs to be a valid value School advisor/counselor's email address This field is required This field needs to be a valid value School advisor/counselor's phone number This field is required This field needs to be a valid value Field of interest or specialization Select a field Physical Therapy Occupational Therapy This field is required Other This field is required This field needs to be a valid value Type of placement you are interested in Internship: A structured, unpaid work experience related to a student’s major and/or career goal. Typically needed for school credit – affiliation agreement needed with school. Job Shadow: An educational program where college students or other adults can learn about a particular occupation or profession to see if it might be suitable for them. No official school credit given. Clinical Rotation: Part of a clinical education program where a student is placed in the department and provides care under the direct or indirect supervision of a healthcare provider. This is usually part of the school’s curriculum, and an affiliation agreement with the school is required. Select a type of placement Select placement type Internship Job Shadow Clinical Rotation Other This field is required Other type of placement This field is required This field needs to be a valid value Describe internship/placement requirements This field is required This field needs to be a valid value Write a brief description of what you hope to achieve during your time at Christie Clinic This field is required This field needs to be a valid value Have you been in touch with someone at Christie Clinic regarding this placement? If yes, who? This field is required This field needs to be a valid value What position are you interested in pursuing? Select position Occupational Therapist Physical Therapist Physical Therapist Assistant This field is required Nice try spambot Availability Expected Start Date This field is required This field needs to be a valid value Expected End Date This field is required This field needs to be a valid value Expected duration of internship/job shadow This field is required Please provide: A. Chronological summary of educational experience This field is required B. Chronological summary of work experience This field is required Nice try spambot Security and Confidentiality Agreement As a team member/student/visitor of Christie Clinic, I agree to the following: I understand that I am responsible for complying with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) policies and procedures. I will treat all information received in the course of my employment with Christie Clinic, which relates to the patients, as confidential and privileged. I will not access patient information without professional "need to know." I will not discuss or disclose information regarding Christie Clinic patients to any person or entity, other than as necessary to perform my job, and as permitted under the HIPAA policies and procedures. I will not discuss patients or their illnesses in public places where conversation may be overheard. I will not invite or permit unauthorized persons into patient care areas of the Clinic. I will not make copies of any records or data except as specifically authorized. I will not log on to any of Christie Clinic's computer systems that currently exist or may exist in the future using a password other than my own. I will not allow anyone, including other employees, to use my password to log on to Christie Clinic's computer systems. I will safeguard my computer password and will not post it in a public place, such as the computer monitor or a place where it will be easily lost, such as on my nametag. I will log off of any computer as soon as I have finished using it. I will not take patient information from the premises in paper or electronic form without first receiving permission from the Privacy Officer or designee. I will report to my manager or the Privacy Officer immediately any unauthorized access or divulgence of confidential records or data, either by myself or someone else. Upon cessation of my employment with Christie Clinic, I agree to continue to maintain the confidentiality of any information I learned while an employee and agree to turn over any keys, access cards, or any other device that would provide access to Christie Clinic or its information. I understand that protected health information (PHI) or data is defined as any information that is identifiable to an individual and is transmitted or maintained in any form or medium, including oral, paper, or electronic, by an employer or a health care provider, health plan, or health care clearinghouse. I have read this agreement and will demonstrate my understanding and willingness to abide by the policies and procedures. I understand that violation of this agreement may result in disciplinary actions, and/or including termination of employment. I also understand that intentional violation could lead to civil litigation including attorneys' fees, costs, and money damages. Yes, I agree to these terms This field is required Signature This field is required This field needs to be a valid value Nice try spambot
