Activity Description: Dental Assisting Clinical                

Transportation: Student MUST have transportation to and from the activity. Transportation is the parent/guardian responsibility.

Student is responsible for finding their own Dental Clinic. A total of 90 hours is required at a clinic.

Clinical experiences are vital in the preparation of health care workers who will work with patients. This course has a required clinical experience component in which the student will observe and/or perform specific health care procedures in direct contact with patients that may include:

o personal care
o patient bathing
o bathroom assistance
o questioning patients about bodily functions
o specimen collection
o assistance with procedures such as a pap smear
o other types of personal contact between student and patient

Each high school student who participates in a course-required clinical experience must have the signature of a parent or legal guardian in order to participate in and complete the clinical experience.

I give permission for my student to participate in discussions, study, and experiences regarding personal care.

I acknowledge that these are duties and responsibilities of health care providers.

I also understand that if I do not consent to have my student participate in these discussions and experiences, my student may not be eligible to become licensed or certified in the program in which they are enrolled.

This Health Information Confidentiality Agreement applies to all students of Jordan Academy for Technology & Careers (“JATC”) who have access to protected health information (“PHI”) maintained, received, or created by any healthcare facility contracted with JATC for clinical rotations.

Please read all sections of this Agreement, before signing below.

Health care facilities have a legal and ethical responsibility to safeguard the privacy of their patients and to protect the confidentiality of their health information. In the course of your clinical experience, whether or not you are directly involved in providing patient services, you may hear information that relates to a patient’s health, read or see computer or paper files containing PHI and/or create documents containing PHI. Because you may have contact with PHI, JATC requests that you agree to the following as a condition of your clinical rotation:

1. Confidential PHI: I understand that all health information which may in any way identify a patient or relate to a patient’s health must be maintained confidentially. I will regard confidentiality as a central obligation of patient care.

2. Prohibited Use and Disclosure: I agree that, except as required under my job responsibilities or as directed by the facility, I will not at any time during or after my work speak about or share any PHI with any person or permit any person to examine or make copies of any PHI. I understand and agree that personnel who have access to health records must preserve the confidentiality and integrity of such records, and no one is permitted access to the health record of any patient without a necessary, legitimate, work-related reason. I shall not, nor shall I permit any person to, inappropriately examine or photocopy a patient record or remove a patient record from the facility.

3. Safeguards: When PHI must be discussed with other healthcare practitioners in the course of my clinical experience, I shall make reasonable efforts to avoid such conversations from being overheard by others who are not involved in the patient’s care. I understand that when PHI is within my control, I must use all reasonable means to prevent it from being disclosed to others, except as otherwise permitted by this Agreement. Protecting the confidentiality of PHI means protecting it from unauthorized use or disclosure in any form, including oral, fax, written, or electronic.

4. Training and Policies and Procedures: I agree that I will read the facility’s policies and procedures as they relate to my job responsibilities, will complete the training courses offered by the facility, and shall abide by the facility’s policies and procedures governing the protection of PHI.

5. Termination: At the end of my clinical rotation I will make sure that I take no PHI with me, and that all PHI in any form is returned to the facility or destroyed in a manner that renders it unreadable and unusable by anyone else. Discharge or termination, whether voluntary or not, shall not affect my ongoing obligation to safeguard the confidentiality of PHI and to return or destroy any such PHI in my possession.

6. Sanctions: I understand that my unauthorized access or disclosure of PHI may violate state or federal law and cause irreparable injury to the facility and harm to the patient who is the subject of the PHI and may result in disciplinary and/or legal action being taken against me, including termination from the JATC program.

7. Disclosure to Third Parties: I understand that I am not authorized to share or disclose any PHI with or to anyone who is not part of the facility’s workforce, unless otherwise permitted by this Agreement.

8. Agents of the Department of Health and Human Services: I agree to cooperate with any investigation by the Secretary of the U.S. Department of Health and Human Services (“HHS”), or any agent or employee of HHS or other oversight agency, for the purpose of determining whether the facility is in compliance with federal or state privacy laws.

9. Disclosures Required by Law: I understand that nothing in this Agreement prevents me from using or disclosing PHI if I am required by law to use or disclose PHI.

By my signature below, I agree to abide by all the terms and conditions of this Agreement.

Dental Assisting taught by Stacy Buss at the Jordan Academy for Technology & Careers 801-256-5925.

Dear Parent/Guardian:

As part of your child’s education, he/she has enrolled in a course that includes instruction on topics
related to sex education. You are receiving this consent form because instruction and/or discussion of
sex education topics are controlled by state law and Utah State Board of Education rule. Please read the
form carefully, select one option, sign, and return to the teacher above. Your student will not be allowed
to participate in class activities without this completed and signed form on file. Thank you.
Information

All instruction related to human sexuality or sexual activity will take place within the context of Utah
State Law (53G-10-402) and Utah State Board of Education rule (R277-474) as follows:
            • The public schools will teach sexual abstinence before marriage and fidelity after marriage.
            • There will be prior parental consent before teaching any aspect of contraception or condoms.
            • Students will learn about communicable diseases, including those transmitted sexually, and
              HIV/AIDS.

Program materials and guest speakers supporting instruction on these topics have been reviewed and
approved by the local district or charter curriculum materials review committee.

The following are NOT approved by the State Board of Education for instruction and may not be taught:
            • The intricacies of intercourse, sexual stimulation, or erotic behavior;
            • The advocacy of premarital or extramarital sexual activity;
            • The advocacy or encouragement of the use of contraceptive methods or devices.

In accordance with Utah State Board of Education Rule R277-474-7-4, teachers may answer spontaneous
student questions to provide accurate data, correct inaccurate or misleading information, or respond to
comments made by students in class regarding human sexuality.

Curriculum for this course includes instruction or discussion about the topics checked below.
  sexual abstinence
  human sexuality
  human reproduction
X reproductive anatomy
X physiology
  pregnancy
  marriage
  childbirth
  parenthood
  contraception
X  HIV and AIDS (including modes of transmission)
 sexually transmitted diseases
 refusal skills

Factual, unbiased information about contraception may be presented as part of this course only if the box above
is checked. Demonstrations on how to use contraceptive means, methods, or devices are prohibited.

Students in health occupations should always be aware of potential contamination from infectious agents in the health care environment. It is important that everyone be alert to prevent accidental exposure. Since it is not possible to identify all patients with transmissible disease, especially in emergency situations, health care providers should treat all patients at all times as if they are a potential source of infection. This approach includes precautions for contact with patients’ blood and body fluids. This is referred to by the CDC (Center for Disease Control) as “Universal Precautions”. Practice of these precautions will provide protection against HIV (Human Immunodeficiency Virus), the cause of AIDS, HBV (Hepatitis B virus), and other blood-borne infectious agents. Rigorous adherence to these guidelines will be required of all students and faculty.

Basic aseptic technique practiced by health care students/faculty in conjunction with the following blood and body fluid precautions can prevent the transmission of HIV, HBV, and other blood-borne agents.

1. All patients, their blood, and other body fluids, will be considered to be infectious at all times.

2. Regardless of patient status, the student and faculty will:

       a. Wash hands thoroughly with soap and water BEFORE and AFTER contact with patients, their blood, urine, or other body fluids.

       b. Consider sharp items (needles, instruments, etc.) as being potentially infective and handle with extreme care to prevent accidental injury.

       c. Wear gloves when handling patient blood, body fluids, and/or items soiled with blood or other body fluids.

       d. Wear gown, mask, and eye covering when performing procedures where splashing or spraying is likely to occur.

       e. Clean up spills of blood or body fluids immediately (while wearing gloves) with a disinfectant such as 1:10 dilution of chlorine bleach.

Procedure for Reporting Potential Exposure

1. Any incident of potential contamination must be reported to and fully documented by the clinical instructor on-site and then to the classroom instructor at the Jordan Academy for Technology & Careers.

2. Assessing the situation and recommending action will be a joint responsibility of the clinical instructor, classroom instructor, JATC administration, and Risk Management specialist.

Each student is required to get the Hepatitis B series of injections. This protects the students from contracting Hepatitis B. The student is responsible for setting up the appointments and following through with the series of injections. The injections can be obtained from the County Health Department or through a private physician.

My student and I have read the Policy on Transmitted Diseases and understand the student’s responsibility in following these guidelines.

Classroom Instructor agrees to accept the following responsibilities:

1. Provide the clinical instructors with a clear explanation of externship requirements, as well as act as a liaison throughout the clinical externship experience to help the student and clinical instructor maximize the externship experience.
2. Provide classroom training in critical work-­related skills.
3. Assist the student in achieving training requirements.
4. Maintain records, verifying that requirements have been met for the student to receive clinical externship credit.
5. This contract may be revoked in any situation where it is found that reasonable precautions have not been observed for the safety of the student.

This is the portion signed by Stacy Buss and kept on file


Clinical Instructors (Externship Site Supervisors) agree to accept the following responsibilities:

1. Provide thorough orientation to the externship site and clearly explain what is expected of the student.
2. Provide ongoing evaluation of the student’s performance.
3. Document attendance, scores and skills performed in the clinical folder on a regular basis.
4. Communicate with the classroom instructor on how the student is doing, including letting the classroom instructor know if there are any problems or concerns that should be addressed.
5. Meet all state and federal safety and health requirements.
6. Report to the classroom instructor accidents or injuries at time of occurrence.

This is the portion signed by the Clinical Instructor and kept on file


CTE Class: Dental Assistant


Student Intern agrees to accept and the Parent/Guardian agrees to support the following responsibilities:

1. Maintain passing grades and regular attendance at school and the clinical site.
2. Follow all rules concerning the clinical program, including notifying the classroom instructor and clinical site supervisor prior to ANY absence.
3. Show honesty, punctuality, cooperative attitude, proper grooming/dress, and willingness to learn while at the clinical site and in all interactions with both the classroom instructor and the clinical instructors.
4. Report immediately any problems or accidents to the clinical and classroom instructors.
5. Provide transportation to and from the clinical site.
6. Understand that the student will be removed from the clinical  portion of the program and will not receive the Dental Assisting Certificate if these rules are not followed.

Leadership Organization: HOSA

I am the custodial parent or legal guardian of the above named student. I understand that my student wishes to participate in the above named, student leadership organization at the Jordan Academy for Technology & Careers. I understand that membership and participation in this organization are voluntary. During approved student leadership meetings, a supervisor will be present to provide supervision and sponsorship and to ensure compliance with applicable school policies.

This student leadership organization has been authorized by the school based on its stated purposes and activities as set forth in the organization’s application and charter. I understand that I may make arrangements to inspect a copy of the application and charter of this organization which describes the nature, purposes, structure, and other information about this organization. I am satisfied that by either obtaining this information from my student and/or inspecting the organization’s charter, I have sufficient information about this organization to make an informed decision regarding my student’s participation. With all of these considerations in mind, I authorize my student’s participation in this student leadership organization. I further understand that my consent may be withdrawn at any time if I notify the school in writing of that withdrawal of consent.

A good reputation enables members to take pride in their organization. HOSA members have an excellent reputation. Your conduct at any HOSA function should make a positive contribution to the reputation that has been established.

1. Your behavior should be professional at all times and reflect positively of you, your school/college, your state and HOSA.
2. Student conduct is the responsibility of the student monitored by the local chapter advisor. Students shall keep their advisors informed of their activities and whereabouts at all times. (HOSA conference name badges shall be worn at all times.) Students should stay in groups and not leave with strangers.
3. You are expected to attend all general sessions and other scheduled conference activities. Please be prompt and show respect to those in the audience and on stage.
4. Members are to report any accidents, injuries or illnesses to their local and state advisor immediately.
5. Members are expected to observe the designated curfew. (Curfew means being in your own room by the designated hour.)
6. Students are responsible for paying any additional room charges-phone calls, movies, food, etc. - as well as any charges incurred for vandalism, damage or theft.
7. Members/participants attending the HOSA event may not purchase, consume or be under the influence of alcohol or drugs at any time. Violators will be subject to stringent disciplinary action.
8. Smoking or chewing tobacco is not allowed.
9. Students who disregard the rules will be subject to disciplinary action and will be sent home at their own expense. Parents will be notified.
10. Students are not to have access to vehicles during the HOSA activity. In case of exception approved by the high school principal and the parent, the student is not to transport or be transported by other students.
11. Members should abide by the dress code during the entire event. Tank tops, mini-skirts, mini-shorts, bikinis, spaghetti straps are unacceptable during the conference.

GENERAL SESSIONS PROTOCOL

The general sessions should be enthusiastic, but must not be rude or obnoxious to those in the audience or on stage. It is important to remain seated until the end of the session. People that do not adhere to general session protocol will be asked to send a representative to a special meeting of the State Executive Council.

I have read the above Code of Conduct for HOSA conferences and activities and agree to abide by these rules as indicated by my signature below.

From time to time our dental assisting class may have the opportunity to watch movies during class time. The movies that will be viewed are for educational purpose and go along with the curriculum your students have been or will be learning. Occasionally, movies may be rated PG-13. This form will be kept on file for the school year.

Movies that may be watched:
Contagion
John Q

Students at the Jordan Academy for Technology & Careers are periodically filmed, photographed or interviewed regarding programs and/or activities at the school. These are used for educational purposes including: the school web site, private class Instagram, news articles, pamphlets, brochures, class activities and projects or to promote the courses offered at the school.

The following website and Apps are used inside and outside of the classroom.
- Classflow website (review activities)
- Dentalcare website (dental educational resources)
- Colgateprofessional (dental educational resources)
- Innerbody website (anatomy section - information)
- BoneBox - Dental Lite (dental app - tooth morphology)