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Job Share Day Request

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Name
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Email
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Telephone
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Address1
Address2
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City
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State
select
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Zip
  
Have you been exposed to any of the illnesses listed below, within the past 2 to 3 weeks?

Check all that apply.







Are you experiencing any of the following symptoms?

Check all that apply.








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Unit/Department Interviewed for:
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Position Interviewed for:
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Date Requested for Job Share Day:

01/01/2011

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Time Requested for Job Share Day:

0930

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Location of Share Day:

In case of emergency, please contact:

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Name
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Relationship
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Home Phone
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Work/Cell Phone

By signing below, I agree to the following:

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    1. The Shadow Day is OBSERVATION ONLY with no "hands-on" experience.
    2. There is potential for exposure to blood and/or body fluids in the hospital setting.
    3. For everyone's protection, Carroll Hospital Center reserves the right to cancel your participation in the Shadow Day program in the event of illness or exposure to a contagious disease within the last 2 to 3 weeks.

Agree:

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Print Signature
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Today's Date

example: 01/01/2011