01. Personal Details

02. Request Details

03. Required Training

04. Confirmation

SIH Job Shadow Application

Opportunities to Explore Various Healthcare Professions

Name

Email

Hometown

Phone number

Date of Birth

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Current Address

Is this your first job shadow experience at SIH?

Yes

No

Are you currently or have you ever been an SIH employee?

Yes

No

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01. Personal Details

02. Request Details

03. Required Training

04. Confirmation

Type of Student

High School Student

College Student

Planning to Apply to Graduate School

Foreign Medical Graduate Student Applying to US Residency

Employed, But Exploring Second Career

Other:

Current School

What is your preferred job shadow schedule?

(i.e. specific available days or times per week.)

Specialty or provider requested (if applicable):

Anticipated Date of Graduation

Please add today's date if this does not apply to you.

MM

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YYYY

Are you interested in working in southern Illinois after graduation?

Yes

No

Possibly

What are your career goals?

What do you hope to gain from this student experience?

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01. Personal Details

02. Request Details

03. Required Training

04. Confirmation

SIH Student Required Training

All students must watch the attached Commitment to Care video & review the following training documents on Compliance, Confidentiality, and HIPAA.

Student-Required Training Documents

REQUIRED TRAINING QUIZ:

To ensure you understand the required training documents, please provide 1-2 sentence answers to these questions:

Based on the above video, how can you support SIH's Commitment to Care?

Based on the above Compliance Training, how should you report any concerns?

Based on the above Confidentiality Policy, what are 3 things that you should keep confidential?

Based on the above HIPAA training, what is HIPAA and an example of PHI?

Terms & conditions
I have read and understand all the SIH Required Training Documents. I agree to be held accountable for SIH policies and procedures including but not limited to SIH Commitment to Care, Compliance Training, Confidentiality Policy, and HIPAA training. I understand violation of these policies will result in immediate termination of my student experience and marked 'not for future hire' at SIH.

I agree to the Terms & Conditions.

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01. Personal Details

02. Request Details

03. Required Training

04. Confirmation

Attach a current CV or resume (optional)

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If you do not already have an SIH Student Badge, upload a JPG headshot photo in front of a blank wall along with this form.

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Please upload a copy of your COVID vaccination. (optional)

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Please upload a copy of your annual flu vaccination if your job shadow experience is between September 1 - March 31.

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Please upload a copy of your annual TB test.

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Proof of health insurance

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studentemail

Verification

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