Children's National Hospital Confidentiality, Liability and General Policies Commitment and Agreement for Episodic Associates agrees to the following rules and regulations regarding participation from (Start Date Below) to (End Date Below). Please note that these dates must fall within a period of five consecutive days. If your dates are beyond five days, please submit an application with the Special Category Program instead as an "Observer."
CONFIDENTIALITY AGREEMENT
By my signature, I acknowledge that the content of discussions and meetings during participation
may include confidential information related to patients, patient care and or organizational processes. I also
acknowledge that any documents or discussions in regard to the observation of patient care and workflow at
Children's National Hospital are considered confidential information and are not subject to disclosure to any
outside parties, and that any and all information regarding patients, parents, employees, and medical procedures
and processes are confidential.
I agree not to disclose any personally identifiable medical information regarding patients, parents, employees or
medical procedures and/or processes at Children's National Hospital of which I acquire knowledge through my
participation in this event, or through discussions and/or written documents. I understand that if I breach this
Confidentiality Agreement, I will be subject to any and all penalties recognized by the District of Columbia and
governing federal laws including the Privacy rules for the Health Insurance Portability and Accountability
regulations. I understand that this confidentiality provision is binding immediately upon my signature of this
document and will be effective for a period of 10 years. If I wish to use any information I obtain during this
activity, whether verbal or written, I understand that I must request authorization in writing from the Legal
Department of Children's National Hospital.
INFECTION CONTROL
Children's National Hospital is committed to protecting patients and visitors from exposure to infectious diseases.
Prior to your visit we ask that you notify us if you've experienced any of the following symptoms within the past 5
days:
Fever (?100°F or feeling feverish but no temperature taken)
Cough, Sore throat, Body aches, chills and fatigue, Rash or other skin infections, Vomiting or diarrhea, By signing below you acknowledge that you are free from the above symptoms AND have not been in close contact with
any sick individuals over the past 5 days. Those answering "yes" to any of the above will not be permitted to
assist. This will help ensure the safety of all patients and staff. We thank you in advance for helping to protect
our patients and our guests.
Additionally, if you become seriously ill within two weeks after your visit to Children's National please notify
Infection Control at 202-476-5053. We ask you to report this information in order to protect our patients.
If assisting during flu season, I will provide proof of a current flu shot with this submission.
WAIVER AND RELEASE OF Liability:
I HEREBY ASSUME ALL OF THE RISKS OF ASSISTING, including by way of example and not limitation, any risks that may
arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or
defective equipment or property owned, maintained, or controlled by them, or because of their possible liability
without fault.
I certify that I am physically fit, have sufficiently prepared or trained for assisting, and have not been advised
to not participate by a qualified medical professional. I certify that there are no health-related reasons or
problems which preclude my participation.
I acknowledge that this Waiver and Release of Liability Form will be used by my supervisor, the event holders,
sponsors, and organizers of the activity or event in which I may participate, and that it will govern my actions
and responsibilities at said activity or event. In consideration of my executors, administrators, heirs, next of
kin, successors, and assigns as follows:
(a) I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising
from the negligence or fault of the entities or persons released, for my death, disability, personal injury,
property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to
and from this event, THE FOLLOWING ENTITIES OR PERSONS: Children's National Hospital, located at 111 Michigan
Avenue NW, Washington, DC, and/or its affiliates, directors, officers, employees, volunteers, representatives, and
agents, the activity or event holders, activity or event sponsors, and activity or event volunteers;
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b) I INDEMNIFY HOLD HARMLESS, AND PROMISE NOT TO SUE Children's National Hospital or persons mentioned in this
paragraph from any and all liabilities or claims made as a result of my participation, whether caused by the
negligence of releases or otherwise. I acknowledge that Children's National Hospital and its directors, officers,
volunteers, non-employees, representatives, and agents are NOT responsible for the errors, omissions, acts, or
failures to act of any party or entity conducting a specific event or activity on behalf of Children's National
Hospital.
I hereby consent to receive medical treatment which may be deemed medically advisable in the event of injury,
accident, and/or illness during this activity or event.
I understand that at this assignment, event or related activities, I may be photographed. I agree to allow my
photo, video, or film likeness to be used for any legitimate purpose by the organization, event holders, producers,
sponsors, organizers, and assigns.
GENERAL GUIDELINES
To ensure a safe and enjoyable experience for all, I agree to adhere to the following guidelines: ALL EPISODIC
ASSOCIATES MUST BE AT LEAST 15 YEARS OF AGE
Distribution of any gift or favor is not permitted without prior approval
To support hospital safety and security, all guests must have a valid ID upon entering the premises. All Episodic
Associates must wear a Children's National Visitor ID at all times.
I affirm that I have not been convicted of a felony or misdemeanor, other than one that has been expunged from my
record or one for which I have been pardoned. I also attest that I have not been barred from working in a
healthcare setting or currently facing sanctions.
If I am visiting the United States on a Visa, I will provide my immigrant status to the Special Category Team to be
approved by the Legal Department at Children's National Hospital prior to participating. Intellectual Property -
Works of authorship, technical discoveries, inventions, marks or other items of commercial interest created by or
resulting from research or investigations conducted by Children's National staff (including employees, faculty
members, fellows, residents, consultants, trainees, students, and volunteers) on Children's National time or by
anyone utilizing Children's National resources shall become the property of Children's National (or other
appropriate Children's National subsidiary and affiliate) or its assignee. Children's National reserves the right
to protect, by patent, copyright, servicemarks, trademarks or other appropriate intellectual property protection
such discoveries or inventions and works of authorship.
I CERTIFY THAT I HAVE READ THIS AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF
LIABILITY AND A CONTRACT AND I SIGN OF MY OWN FREE WILL.
