Student Externship/Observation Agreement


I will keep all patient information confidential. I will disclose patient information in accordance with the policies of the facility that I am assigned to during my student externship experience. Furthermore, I understand and agree to comply with the guidelines set forth by HIPAA.

I will not discuss any information, patient-related or relating to the operations of the facility to include my own health record if applicable. I will keep all security codes and passwords used to access the facility, equipment and computer systems confidential.

I will access or view patient information only as it is required in the scope of my student experience to include my own health record if applicable.

I will not disclose, copy, transmit, modify or destroy patient information or other confidential practice information without the permission of my supervisor or the practice’s privacy officer.

I agree to comply with these conditions even after my student externship experience is terminated.

I understand violation of this agreement may result in disciplinary action, up to and including termination from the externship and dismissal from my program. My signature on this agreement indicates that I, a student of MedCertify have read, understand and will comply with all aspects of this confidentiality agreement.



MedCertify students are responsible for:

  1. Reading this student information sheet and following the guidelines.
  2. Identifying the appropriate contacts on campus and at externship sites.
  3. Paying for all expenses either through their own health insurance or other personal means associated with testing, medications, and related costs.
  4. Providing medical expenses to include blood work requested of source patients.

If you experienced a needle stick or sharps injury or were exposed to the blood or other body fluid of a patient/student during the course of your extern/study, immediately follow these steps:

  • Wash needle sticks and cuts with soap and water
  • Flush splashes to the nose, mouth, or skin with water
  • Irrigate eyes with clean water or saline
  • Report the incident to your instructor
  • Refer to exposure control plan and fill out exposure report form
  • Students should have appropriate initial laboratory tests if needed per current CDC guidelines performed as soon as they can get and appointment but no later than the next business day

Students are not an employee of the school ; therefore, they are not eligible for worker’s compensation benefits (although they may be required to complete similar paperwork to document the details of the exposure). The student will be responsible for the cost of their care, either through their own health insurance or other personal means. All source patients are encouraged to have blood work as designated by the CDC protocol current at the present time (presently HCV antibody, HIV antibody, and Hepatitis B surface antigen). The student requesting the blood work may be held responsible for the cost of treatment for the source patient.

Students will be directed to have source patient information available for their discussion with the appropriate personnel at the outside facility, if available, concerning the exposure:

  • Approximate time of exposure
  • Location of exposure (e.g., school, medical or dental office, etc.)
  • Source of the exposure (e.g., blood, contaminated instrument, etc.)
  • Type of exposure (e.g., skin, mucous membrane percutaneous)
  • Length of exposure (e.g., seconds/minutes/hours)
  • Status of the source patient: Negative, Positive, or Unknown HIV, HBV, and HCV status
  • Whether or not patient is at risk for HIV,HBV, or HCV infection because of:
    • Multiple blood transfusions 1978-1985
    • IV drug user
    • Multiple hetro- or homosexual partners
    • Known HIV positive and/or have symptoms of AIDS, HBV or HCV
    • Significant blood or bodily fluid exposure has occurred

MedCertify will not be held responsible nor pay expenses incurred from student exposure, to include needle sticks. MedCertify recommend students seek medical treatment if necessary and to follow the treatment protocol advised from the medical facility at the expense of the student. Students assume their responsibility upon enrollment as there are risks associated with study and employment in the healthcare field.



By signing the agreement you are agreeing to the following:

I am currently enrolled as an Allied Health student at MedCertify. I have been informed and understand that due to my possible exposure to blood and other potentially infectious substances, I may be at risk of acquiring TB, Hepatitis B, HIV infection or other infectious contagions.

I have been advised that vaccination for Hepatitis B is available through any local physician and is recommended by MedCertify and the instructors therein. I understand that Hepatitis B is a serious disease.

I have been advised that I am required to obtain TB testing before I may begin Observation/Externship. Dental students have been advised that the school also recommends TB testing before beginning the skills portion of the dental program.  

I have been given the opportunity to ask questions about inoculation and risks involved in receiving the vaccines and in declining vaccination. My questions have been answered to my satisfaction. I understand that  is not responsible for my attaining vaccinations or liable in the event that I should contract any contagion during my education. I understand my externship site may request records before attendance, and I am responsible for obtaining them in a timely manner.


MedCertify students are required to obtain "Healthcare Provider" CPR to begin externship/observation. Documentation is required to be presented prior to being placed at a facility. 



MedCertify promotes a professional atmosphere and requires a clean, ironed uniform. Students need to wear closed toed shoes and royal blue scrubs. 



To be in compliance with OSHA standards on bloodborne pathogens, each student must be informed of the mandatory Universal Precautions in all healthcare settings. These standards and precautions are included and covered in detail within the courses. This must be completed by the student prior to externship eligibility. It is also required that students be informed and encouraged to begin the Hepatitis B vaccine series. However, you may decline vaccination at this time. Students are required to read and sign the Hepatitis B Statement of Informed Consent prior to placement in an externship facility. Students will be required to meet all OSHA requirements on the externship. In addition, each individual facility may have some variation of these rules and regulations and it is the student’s responsibility to obtain a copy of these rules and regulations at that externship site. Those regulations set forth by that facility, must also be met by the student.


Leave this empty:

Signature arrow sign here

Signature Certificate
Document name: Student Externship/Observation Agreement
lock iconUnique Document ID: 87c6f738a499ad51688807e23de5c660023decec
Timestamp Audit
July 14, 2022 9:45 AM ESTStudent Externship/Observation Agreement Uploaded by MedCertify Education - [email protected] IP 2600:1700:7b18:ec90:5cc1:178c:b928:c586
July 14, 2022 9:48 AM ESTMedCertify Edu - [email protected] added by MedCertify Education - [email protected] as a CC'd Recipient Ip:
July 14, 2022 9:50 AM ESTMedCertify Edu - [email protected] added by MedCertify Education - [email protected] as a CC'd Recipient Ip:
May 2, 2023 1:20 PM ESTMedCertify Edu - [email protected] added by MedCertify Education - [email protected] as a CC'd Recipient Ip: