Job Shadow Application

Before you begin this application, be advised that Aspirus has certain immunization requirements and you need to provide the dates you were immunized for the following:

• The date of your most recent tuberculosis (TB) test, if applicable.
• Last two MMR vaccinations, MMR titer showing immunity, or explanation of incomplete vaccination series.
• Last two Varicella vaccinations, Varicella titer showing immunity, or explanation of incomplete vaccination series. Aspirus does not accept “History of Disease” as proof of immunity.
• Hepatitis B vaccination status or Hepatitis B declination.
• Flu vaccination proof or declination. Please note: Indicating you have received your flu shot will require you to upload documentation showing proof. Be sure to have the file on your device prior to beginning the application.
• COVID-19 vaccination proof or declination. Please note: Indicating you have received your COVID-19 vaccination will require you to upload documentation showing proof. Be sure to have the file on your device prior to beginning the application. COVID vaccinations are currently required.

This information is often not common knowledge, so you may need to contact your physician’s office or obtain a copy of your medical record. You are encouraged to have this information before starting the application, as you will not be able to save your progress.

SCHOOL INFORMATION

* Denotes required field

• School or organization: *

STUDENT INFORMATION

• Student first name: *
• Student last name: *
• Date of Birth: *
• Student email: *
• Personal email: *
• Primary phone:

• Address: *
• City: *
• State: * Please select state... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming
• Zip: *

PLACEMENT INFORMATION

• I would like to shadow a...* -- select -- CRNA Laboratory Scientist Medical Assistant Nurse Nurse Practitioner Occupational Therapist Physician Assistant Physical Therapist Physician Radiology Technician or Ultrasound Respiratory Therapist Speech Therapist Surgical Technician Other
• Degree or program:
• Preferred Aspirus locations: * Aspirus Divine Savior Hospital and Clinics (Portage)Aspirus Eagle River Hospital and Clinics
  Aspirus Iron River Hospital and ClinicsAspirus Ironwood Hospital and Clinics
  Aspirus Keweenaw Hospital and ClinicsAspirus Langlade Hospital and Clinics
  Aspirus Medford Hospital and ClinicsAspirus Merrill Hospital
  Aspirus Ontonagon HospitalAspirus Plover Hospital
  Aspirus Rhinelander HospitalAspirus Riverview Hospital and Clinics
  Aspirus Stanley HospitalAspirus Stevens Point Hospital
  Aspirus Tomahawk HospitalAspirus Wausau Hospital and Clinics
  Howard Young Hospital - Woodruff
  
• Department: *
• Preferred person to shadow (first and last name):
• Hours requested: *
• Dates available to shadow: *

Are you a current Aspirus employee? * Yes
No

Check all that may apply to you: Former Aspirus Employee
Former Student at Aspirus
Interested in Employment at Aspirus and I give my permission to use my contact information for recruitment purposes within the Aspirus Health System

HEALTH HISTORY

Do you have allergies? * YesNo

Do you need an Epi-Pen? * YesNo

Pregnancy notice: * If you are placed in Imaging Services or Surgery and could possibly be pregnant, please notify your instructor, as exposure to some procedures could be harmful to your unborn child. By checking this box, you acknowledge that you have read and understand this notice. *This is a required field.

IMMUNIZATION REQUIREMENTS

Aspirus has certain immunization requirements. To complete the information below, you may need to contact your physician’s office or obtain a copy of your medical record.

We require the dates of your two MMR (Measles, Mumps, Rubella) vaccination dates/the date of your most recent MMR (Measles, Mumps, Rubella) titer showing immunity or an explanation of incomplete vaccination series. Indicate the date(s) or explanation you will be providing below to reveal the corresponding fields: * Vaccination Series
Titer
Explanation

We require the dates of your two Varicella vaccines/the date of your most recent Varicella titer showing immunity, or an explanation of incomplete vaccination series (history of Varicella is not accepted by Aspirus as proof of immunity). Indicate the date(s) or explanation you will be providing below to reveal the corresponding fields: * Vaccination Series
Titer
Explanation

Indicate your Hepatitis B vaccination status: * I have had all 3 vaccinations and Immune titer
I am in the process of completing the vaccine series
I have not completed my vaccine series and/or I do not have an immune titer and choose to decline

What is your current flu vaccination status? * I have received my annual flu vaccination
I have yet to receive my annual flu vaccination
I choose to decline my annual flu vaccination

What is your current COVID-19 vaccination status? * I have been vaccinated against COVID-19
I choose to decline COVID-19 vaccination

ONBOARDING DOCUMENTS REVIEW

Please open, save and then review the documents below as a condition of your placement with Aspirus.

• Code of Conduct
• Compliance
• Confidentiality Policy
• Drug and Alcohol Free Workplace Policy
• Infection Prevention
• Rapid Regulatory Compliance Part I
• Rapid Regulatory Compliance Part II
• Sexual Harassment
• Social Media/Networking Policy
• Use of Personal/Company Provided Electronic Device Policy

SIGN-OFF

Once you have reviewed the onboarding documents above, please check the box below indicating your compliance with our student onboarding procedures.

I certify that I have completed the Aspirus student on-boarding annual competencies, Human Resources policies and all Employee Health requirements. By checking this box, I certify that I am responsible for understanding the information contained in all requirements. Falsifying this statement or failure to comply with Aspirus policies will result in disciplinary action that may include expulsion from the facility for the remainder of the clinical experience. *This is a required field.

ADDITIONAL COMMENTS

If applicable, please provide any additional information we should know:

Step 1 of 3. Next: Tuberculosis Symptom Questionnaire & Risk Assessment