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2012 Hopkins Medicine Summer Programs- Individual Student Information for 18 years old and older

Johns Hopkins University School of Medicine's (JHUSOM) Office for Student Diversity is now overseeing the registration, approval process, and verification of required documents in order to receive a JHUSOM ID badge.
 
DIRECTOR OR ADMINISTRATOR OF THE SUMMER PROGRAM SHOULD COMPLETE THIS FORM. DO NOT LET YOUR SUMMER PARTICIPANTS COMPLETE THIS FORM.
 
This form needs to be filled out for every summer program participant (paid or unpaid) who is 18 years and older. There is another form for summer participants between ages 14-17 years old.
 
The information is need to be in compliance with university, state, and federal policies. Note that it may take 2 to 3 weeks to collect/verify required information for this form, so please plan accordingly. For more information, please contact Daniel H. Teraguchi, Ed. D., Assistant Dean, Student Affairs at 410-614-8759. Requirements for summer participants to be on campus.
 

Requirements for summer participants to be on campus.

  1. Cover Sheet/Check List (Use one cover sheet for each individual summer participant package of required documents)
  2. Johns Hopkins Medical Institutions' ID Form
  3. Confidentiality agreement
  4. Code of conduct signed by both the summer program participant and parent/guardian
  5. Supervisor/host agreement of expectations signed by supervisor/host and summer program participant
  6. Criminal Background check (if 18 years old or older)
  7. Proof of Health Insurance for anyone 18 years old or older: This can include a copy of insurance card (front/back) or any document that verifies that the summer participant is covered by health insurance. You will need to bring copies of the required documents for each summer participant to the Office for Student Diversity (Broadway Research Building, Suite 137, 733 N. Broadway, Baltimore, MD 21205, 410-614-8759).

All forms are available at: http://www.hopkinsmedicine.org/som/students/diversity/Summer_Programs/index. Templates for consent, code of conduct, and supervisor expectations/responsibilities are also available on the website.

Additional requirements if interacting with patients or patient records in any capacity.

  1. Signature Sheets for Two Knowledge Tests in Orientation Packet: First Knowledge Test covers Nosocomial Infection, Hazardous Drugs and Body Waste, Bloodborne Pathogens, Latex Safety, Environmental Safety, and Patient Confidentiality and Second Knowledge Test covers Age-Specific Care. Additional informational sections include in the packet: Liability and Patient Bill of Rights and Responsibilities.
  2. HIPAA training certificate showing completion of intermediate privacy course for health care providers.
  3. Proof of immunity to Measles, Mumps, and Rubella (MMR) (a copy of your medical records verifying the summer program participant has been vaccinated for MMR)
  4. Tuberculosis (TB) screening

Required forms and materials along with information on the other requirements is available at http://www.hopkinsmedicine.org/som/students/diversity/Summer_Programs/index.

Fields marked with * are required.
Individual Summer Participant Information
(This form is for summer participants who are 18 years old or older as of May 1, 2012)
Enter name exactly as it appears on official documents.
Enter name exactly as it appears on official documents.
Enter name exactly as it appears on official documents.
Please Choose One*
Johns Hopkins University records the demographics of summar participants. This is helpful to understand who Hopkins is serving through the summer programs.
Gender (Optional)
Race (Optional) Check all that Apply
Emergency Contact Information
This information will enable program directors to contact the parent/guardian in case of an emergency.