Engagement of Visitors or Shadowing Non-Professionals

Statement of Policy

Washington University and its faculty, staff, volunteers and workforce members (collectively, “Washington University” or “WU”) have a tradition of participating in a variety of medical, nursing and other educational programs, including job-shadowing opportunities to observe professionals at work, internships for selected high school, and college students or bring your child to work events. WUSM also works closely with visiting physicians or other health care providers, vendors and consultants who may observe or participate in the delivery of care within its facilities but who do not otherwise qualify as members of WUSM’s Workforce. All of these groups are described generally as our Visitors. In order to continue to participate in these valuable programs and permit valued individuals to facilitate care within our facilities while ensuring the privacy of our patients and staff members, we have instituted this Policy and incorporated a procedure regarding the use and disclosure of Protected Health Information (“PHI”) when Visitors may be present.

Scope of Responsibility of All WUSM Employees

Every WU employee is responsible for being aware of, and complying with, the Privacy Regulations and WU’s corresponding privacy policies and procedures. Questions or issues regarding the Privacy Regulations shall be directed to the employee’s HIPAA Liaison, or the HIPAA compliance officer for WU.


This policy shall govern the use and disclosure of Protected Health Information by individuals in WU clinical practices or affiliated hospitals or entities for limited and authorized educational or consultant activities as more fully described above.

Visitor Types:

1. Temporary Student Observation

Students may be eligible for job observation, shadowing or internships within WU (“Visitors”). In participating in such programs, the facility staff, or sponsor (herein “Sponsor”) will be responsible for supervising the Visitors who may be exposed to PHI. Visitors younger than 16 may be part of a sponsored tour group or individual program sponsored by a facility or individual staff member. Visitors do not include individuals, such as medical students or nursing students, who participate at a facility through a formal student or affiliation agreement. For sponsored group tours, the chaperone for such group may sign the confidentiality statement on behalf of the group participants younger than 16 18 years of age.

2. Vendor/Consultant Observation

Vendors and visiting physicians (collectively Visitors”) are sometimes invited to a facility to observe equipment use or to assist in a learning experience.

Washington University Workforce Responsibilities

Workforce member that coordinates visit or “Sponsor” will be accountable for supervising these Student Visitors or Visitors. Sponsor will be responsible for ensuring that PHI is protected in compliance with WU HIPAA Privacy policies. Orientation or review of basic Privacy HIPAA regulations should be completed and should include but not limited to:

  • Obtain signed Confidentiality Agreement by Visitor or their guardian if under 18 years of age. See exhibit A.
  • Complete Non-Appointee Process – to be returned to Human Resources
  • Complete WU HIPAA training if visit is greater than 2 weeks
  • Refer to, and complete specific BJH and SLCH facility requirements if visit will coincide at either entity. (such as TB testing, and proof of vaccinations)
  • Obtain proper ID badge:

WU non- appointee issued badge for anyone over 2 weeks
Name sticker for those visitors here less than 2 weeks

  • Seek any and all patient’s approval prior to any interaction with visitor
  •   Instruct of the need for all PHI to remain on WU property
  • Review how and where to dispose of PHI at WU

Confidentiality Agreements (one for minors and one for adults) (Exhibit A) must be signed before the Visitor participates in the sponsored activity within the facility. Visitors younger than 18 must also have a parent or legal guardian sign the Confidentiality Agreement. All Visitors must have an ID badge to identify them in the facility, to signify completion of the orientation and to confirm that a Confidentiality Agreement has been signed. The Visitor must use an ID badge provided by the WU Member. For groups, one ID badge may be issued to the chaperone or one individual in the group, and the other members of the group may wear an employer or school picture ID badge to identify them as a member of the group.
The Sponsor must also acknowledge his or her responsibility in ensuring patient confidentiality in supervising the Visitor by signing the acknowledgment portion of the Confidentiality Agreement. The Department where the sponsored activity will occur may develop additional materials for orientation including any restrictions for the Visitor. The WU HIPAA Liaison or designee shall serve as the contact person for having the Visitor Confidentiality Statement signed and the ID badge issued.

Creation Date: June 29, 2010
Effective Date: June 29, 2010
Revised Date: September 5, 2014