Preceptors

Thank you for taking the time to help improve our community. We understand how busy you are and respect your beneficence. We appreciate you agreeing to supervise Midwestern University’s students as they participate in patient experiences involving the delivery of free services to indigent and homeless populations. Please read this form thoroughly BEFORE you participate in any Health Outreach through Medicine and Education (H.O.M.E.) activities. You can print a copy for your records.

Your responsibilities:  I confirm that I have an active Arizona license in good standing pursuant to Title 32 of the Arizona Revised Statutes.

I agree to ensure that the University students are appropriately supervised in accordance with professional standards and law. 

Any services that I provide will be within the scope of my practice, and I will not receive compensation for these services. 

Conduct Code:  I will conduct myself appropriately as a representative of the H.O.M.E. student club and Midwestern University.  I agree to exhibit the highest ethical and professional behavior as a model to promote similar behavior in future healthcare professionals.

I agree to work toward better public relations with the general public on behalf of all the programs of Midwestern University and H.O.M.E..

Safety/Disease Prevention:  I agree to follow appropriate universal precautions, and take full responsibility for having obtained this training in my course of practice.

I understand that I am responsible to keep all my immunizations and tuberculosis testing up to date, as required for patient care. Tuberculosis 1-step PPD skin test or, if needed, the 2-step tuberculin skin test, or Quantiferon Test every 12 months, or evidence that I am free of symptoms of pulmonary disease, including a chest x-ray if the skin test is positive; proof of immunity for Varicella, Mumps, Rubella (German Measles), Rubeola (Measles) and Tetanus/Diphtheria; and evidence of completion of the series of three Hepatitis B vaccinations (if required by applicable law or Teaching Practitioner’s policies, or documentation of declination in accordance with the applicable regulations), and rabies vaccination if in animal care. Because of the high risk nature of homeless shelters, the Director of H.O.M.E. also recommends immunizations for COVID-19 and influenza October through March annually.  

I recognize that although these immunizations and testing are strongly recommended by the Director of H.O.M.E., they are not required for licensed professionals to participate in the program.

I agree to follow the direction of the H.O.M.E. student coordinators, all site staff and security.

Each group will meet on campus prior to departure. I understand that I am not required to meet the students on campus to drive for carpool, but that I may do so if desired.  

I agree to always travel with other faculty, preceptors, students or staff in at least groups of two, and will not be unaccompanied while at the shelter(s).  I understand that within the homeless community are untreated psychiatric patients. If you ever feel threatened, please notify your site coordinator. There is security at all of the sites that we visit.

Audio- Videorecording, Photos:   Audiorecording, photos, videorecording and/or digital recording in any format, including cell phones, at H.O.M.E. community sites is prohibited.

When participating in H.O.M.E. activities, I understand that I may be photographed for print, videotaped, or electronically imaged. Images may be used in promotional materials, news releases, and other published formats for H.O.M.E., and will be the sole property of Midwestern University and H.O.M.E.

Harrassment/Discrimination:  I agree to adhere to Midwestern University’s policy of nondiscrimination for all patients, students, faculty and staff regardless of race, color, gender, gender identity, sex, sexual orientation, religion, national origin, ethnicity, disability, status as a veteran, marital status, pregnancy status, housing status or age.

Information Technology:  I understand that H.O.M.E.’s computing and communication resources are the property of MWU.  If found to have misused H.O.M.E. computer services or equipment I will be subject to restitution of funds and may be in violation of Arizona laws. 

Liability: I agree to maintain professional liability insurance coverage at levels appropriate to my field of practice, and to provide the University with proof of coverage. 

I will comply with all federal, state, and municipal laws, advice, policies, procedures, rules and regulations applicable to the provision of health care services.  

I agree to indemnify, defend, and hold harmless the University, its Board, employees and students for any allegations, claims, damages, or other liabilities (of whatever kind or character) arising out of, or relating to, any acts or omissions, or intentional misconduct by you, your affiliates, officers, directors, representatives, assignees, employees, volunteers, or agents. 

University responsibilities: Midwestern University will academically prepare students in theoretical knowledge, basic skills, professional ethics, and OSHA and HIPAA provisions.  

Students are required to have physical examinations; and all tuberculosis testing and immunizations as described above.

Students are required to adhere to the following dress code:  casual dress slacks or scrub pants, and H.O.M.E. T-shirt, dress shirt or scrub top, with student MWU identification badge in full view.  Hair should be clean, neat, combed.  No open toed shoes, halter tops, tank or tube tops, backless, cleavage or midriff-baring tops, white trousers, jeans, capris or shorts, yoga pants, short skirts (must extend to TOP EDGE OF THE PATELLA) or visible body piercings (except ears).  As the event preceptor, you have the authority to prevent students who are inappropriately attired from interacting with patients, at your discretion.

The University requires students to follow all policies, procedures, rules and regulations established by the facility and provided to the University where free services are being rendered.

Students will have and maintain, at their sole cost and expense, health insurance coverage. 

All policies and pronouncements in the Student Handbook are currently in effect and apply to all students enrolled in the University, including off-campus activities such as H.O.M.E.

Vicarious (but not individual) professional liability insurance during clinical education is provided by the University.

Additional information about Arizona State legislation surrounding providers supervising students and/or providing free health care can be found here:  A.R.S. § 12-564 & A.R.S. § 12-571--Qualified Immunity.docx 

Thank you for joining us!