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Affiliated Student Attestation Form

I certify that I have read and completed all the requirements of the University of Mississippi Medical Center (UMMC) Orientation information. I understand that I am required to comply with all hospital policies and the directions of the supervising physician, nurse or other personnel.

I acknowledge that I have read, understood, and agree to abide by the UMMC Compliance Training provided. I understand that I am required to maintain confidentiality of all patient information to which I have access

I acknowledge that I have viewed the Information Security Awareness video and have read, understand, and agree to abide by the requirements set forth in the UMMC Acceptable Use Policy.

I certify that I am compliant with all UMMC TB screening and immunizations. I understand that I must obtain the influenza vaccine during influenza season and provide the documentation to my home program.

I understand that I will not be considered to be an employee of UMMC and agree that I will not be compensated financially. I also understand that I am not entitled to any benefits available to UMMC employees.

I agree to conduct myself in a professional manner at all times while on the UMMC campus and will support the hospital's mission of providing model care.

For current UMMC employees only:

I understand that the affiliated student/instructor placement is separate from my UMMC employment and must occur outside of any paid UMMC work hours. I certify that I will obtain a second UMMC ID badge and wear at all times during the affiliated student placement to identify myself to patients, faculty, and staff as and affiliated instructor or student in training. I understand that access to the medical record during the affiliated student placement must occur in the assigned Epic affiliated student/instructor role.

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