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Mecklenburg EMS:
Clinical Field Experience Identification & Emergency Contact Form.

We offer clinical field experience to partnering agencies. EMT and paramedic students riding with us perform clinical skills under the supervision of a preceptor. Nursing, other medical, and physician riders (students or licensed) with us may shadow only and cannot perform skills. 

Completion of this form is required for all EMT and paramedic students, Atrium Event Health employees, nursing, medical, and physician riders. It should be completed as soon as the shift is scheduled. Once submitted, the information is entered into a database and referred to by our OAs (Operating Assistants) upon your arrival. Failure to complete this form >48 hours before your scheduled shift can result in a cancellation of your ride-along. 

The form is intended to verify your identity upon arrival at Medic and provide emergency contact information. You will only need to complete it the first time you are scheduled to ride with us.

Please read the rider expectations carefully. Our OAs strictly follow these expectations and will cancel your scheduled shift if you do not meet them. If your shift is cancelled, advise your instructor. Instructors are to contact the Clinical Coordinator ONLY within business hours. Do not expect resolution at the time the shift is cancelled.

Please let your instructor know how your experience went. We use feedback to make improvements and to acknowledge our crews that have provided an excellent clinical experience. 

Thank you for riding with us!

RIDER EXPECTATIONS

Dress Code: 

Clothing:
  • Shirt: One color polo-style shirt or department/agency/school uniform shirt. Current certification patches are permitted.
  • Pants: Black/Dark Blue slacks/EMS pants. 
  • Shoes: Black athletic shoes or black EMS-style boots.
  • School uniform ID: desirable but not required.
  • Consider having appropriate gear for inclement weather. We are often outside for long periods.

Appearance:

  • Clean, neat appearance.
  • Medic’s Appearance Policy standards must be met. Pay particular attention to these items. (A copy of the policy is provided below.) 
    • Facial hair policy: Must be clean-shaven or goatee-style beards and mustaches only. 
    • Piercings: 
      • No eyebrow, lip, or visible transdermal piercings are allowed. 
      • You may wear a nose piercing with a stud-style insert up to 1 mm or a nasal septum piercing that is not visible.

Additional:

    • Photo ID: MUST BE CARRIED ON YOU AT ALL TIMES DURING YOUR SHIFT

Arrival Time:

    • Arrive 15 minutes before the start of your shift.
      •  Late arrivals will result in the cancellation of the scheduled shift. 
      • Crews cannot be held from deploying due to the delay or lateness of a student.

During the shift:

  • You must wear seat belts at all times when the vehicle is in motion, unless it is impossible to do so.
  • You may not drive the ambulance at any time for any reason.
  • Individuals who are not riding as part of a contracted clinical field experience are not permitted to treat patients and are only permitted to observe and perform limited tasks as instructed by the crew.
  • You are expected to observe courteous, common-sense behavior towards our patients, crews, facility staff, and any other people you may come into contact with while on our ambulance.
  • Riders are expected to follow all directions from the crew and to adhere to all safety rules, including wearing any personal protective equipment as directed by the crew.

Riders who do not comply with these expectations will be asked to leave and may not be allowed to ride in the future with Medic. 

These rules are subject to change and/or revision at any time with/without notice.

Click here for the Medic Appearance Policy.

STUDENT RIDE ALONG APPLICATION
Now that your shift is scheduled, complete and submit this form. It will provide Medic with a method of identifying you on arrival and provide contact information in case of emergency. This form must be completed >48 hrs prior to the start of your shift.

EMERGENCY CONTACT

ADDITIONAL INFO

Click or drag a file to this area to upload.
JPG FORMAT ONLY (do not use heic files). For you to ride with us, we will require a copy of a valid photo ID. A student ID is acceptable, a driver's license is preferred. ****You must have your ID with you the day you ride with us.

CONFIDENTIALITY AND DISSEMINATION OF PATIENT INFORMATION

  1. Given the nature of our work, it is imperative that we maintain the confidentiality of patient information that we receive in the course of our work. Mecklenburg EMS Agency prohibits the release of any patient information to anyone outside the organization unless required for purpose of treatment, payment, or healthcare operations and discussions of Protected Health Information (PHI)within the organization.
  2. Acceptable uses of PHI within the organization include, but are not limited to, exchange of patient information needed for treatment of the patient, billing, and other essentials healthcare operations, peer review, internal audits, and quality assurance activities.
  3. I understand that Mecklenburg EMS Agency provides services to patients that are private and confidential and that I am a crucial step in respecting the privacy rights of patients. I understand that it is necessary in the rendering of services, that patients provide personal information and that such information may exist in a variety of forms such as electronic, oral, written, or photographic and all such information is strictly confidential and protected by federal and state laws.
  4. I agree that I will comply with all confidentiality policies and procedures set in place by Mecklenburg EMS Agency during my entire association with Medic. If I, at any time, knowingly or inadvertently breach the patient confidentiality policies and procedures, I agree to notify Medic immediately by sending an email to MadisonK@medic911.com. In addition, I understand that a breach of patient confidentiality may result in suspension or termination of my association with Mecklenburg EMS Agency.
  5. I understand that I may never take pictures or patients or scenes, write down patient information, or in any way use or release patient information during or after my ride time with Medic. This includes patient names, date of birth, dates of transport, pickup or drop off locations, medical status or any other information associated with any patient I encounter during my association with Medic.

ACKNOWLEDGEMENT

I, the undersigned, hereby request to accompany the Mecklenburg EMS Agency personnel on emergency and routine medical calls for the purpose of expanding my personal and professional interests and abilities. I am fully aware of the potential risks and dangers involved, the possibility of witnessing emotionally traumatic situations and that unexpected dangers may arise during such activities. I assume all risks of injury to my person, both mental and physical, or property that may be sustained in connection with the stated and associated activities.

In consideration that permission is granted to me to ride on a Mecklenburg EMS Agency ambulance, I do hereby, for myself, my heirs, administrators and assigns release, remise and discharge the Mecklenburg EMS Agency from all claims, demands, action and causes of action of any sort, for injuries sustained by my person, both mental and physical and/or property during my presence on said premises and participation of the stated activities.

I represent myself and certify that my true age is stated below. I certify that my attendance and participation in the above stated activities is voluntary and that I am of sound body and mind.

I certify that I fully read the waiver and release, confidentiality forms and guidelines. I certify that I fully understand all that has been written as it applies to me.

Lastly, I understand that any rider - at any time or reason shall be subject to removal and/or rejection from this program without explanation.