GROUP A CLEARANCE FORM

INSTRUCTIONS - PLEASE READ CAREFULLY!

Step I Please read the Confidentiality Statement, then complete and sign Section A.
Step II During the months of October through March, you must submit a copy of your current seasonal flu
shot documentation with this Form. NO flu shot declinations will be accepted.
Step III Submit your paperwork by mail, fax, or scan/email. An incomplete Form and missing flu shot
documentation (October to March only), will delay the start of your experience.
Mail: Gwen Wysocki -- 11255 Mountain View Ave., Suite 11 -- Loma Linda, CA 92354
Fax: (909) 558-3541 (cover sheet required)
Email: gwysocki@llu.edu
CONFIDENTIALITY / WAIVER STATEMENTS
My signature below indicates that I agree to adhere to a strict code of confidentiality, both verbally and in written material.
All information obtained from clients/patients, their records, or computerized data is to be held in confidence. No copies
of client/patient records shall be made, and no records or computer printouts, or copies thereof are to be removed from
LLUMC or any of its hospital facilities unless pre-approved authorization is obtained by designated personnel. If preauthorization is obtained, all patient information must be de-identified. Clients/patients will not be identified in any manner
in paper, reports, or case studies undertaken by me, for any reason.
As an Observer, I hereby waive, release and forever discharge LLUMC and its affiliated entities, associates, partners,
agents, employees and volunteers of and from any and all matters, claims and suits of every kind whatsoever which the
above signed may have or which may hereafter accrue as a result of or in any way connected with participation in any
observation at LLUMC or its affiliated entities. I further agree to assume any and all risks and to release and hold
harmless LLUMC and its affiliated entities, associates, partners, agents, employees and volunteers who, through
negligence, carelessness, or otherwise might be liable to the above signed for any personal injuries, loss, cost, wages
and any and all other damage resulting from or connected to the above signed for participation in any observation.
I also agree that NO electronic devices and NO video/photo-taking will be permitted anywhere at LLUMC. Failure to
abide by this Statement will result in the immediate termination of my experience and possible compliance and legal
action. LLUMC reserves the right to terminate an observation experience at any time, for any reason.
My signature below indicates that I have read through the Observation Orientation Guide, and that I will take
responsibility for the information contained in it. I will also take responsibility for the Ten Rules of Observation.
Name of the person who referred you to Gwen Wysocki: Arthur Gaitan
What is the purpose of your request to observe? I would like to view Loma Lindas ED Facility as a prospective
staff member or student in the near future

Your Name

Arash Nikookar

Email Address A.Nikookar04@gmail.com

Street/Mailing Address 2514 N. Mountain Ave.

City/State/Zip Claremont CA 91711
Signature
FOR STAFF DEVELOPMENT USE ONLY
Clearance Signature
Manager of Academic Relations
10/12 GroupAClearanceForm1213.doc

Phone 909.996.6306
Date

Date