ATI Student Observation Policy Packet Thank you for your interest in ATI Physical Therapy! In order to submit your request, and complete your observation hours, please fill out this page and sign the following policy pages. Students/Observers are considered the employees and a parent/guardian or friend must sign the witness line. For the photo release form, on the last page, please only sign once. You must choose to opt in or opt out of our photo release waiver. You can only upload one attachment to the observation request webform, so if you need to send additional pages you may do so via Sarah Kaiser at sarah.kaiser@atipt.com. We look forward to having you visit our clinic! Student Name: Region Request (East/Midwest/West): Email:
CONFIDENTIALITY AGREEMENT You acknowledge that, by virtue of your employment by ATI Holdings LLC or Athletic & Therapeutic Institute of Naperville, LLC and all of its affiliates, parents, subsidiaries, predecessors and successors, (herein collectively referred to as ATI ), you will be granted otherwise prohibited access to confidential information belonging to ATI, which is not known either to its competitors or within the industry generally. As used in this Agreement, the term Confidential Information includes, but is not limited to, marketing strategies and plans, financial data, pricing policies, contract provisions, databases, consulting methodologies and process, therapeutic documentation, the identities of current and prospective clients, and clients particularized preferences and needs. Confidential Information also includes, without limitation, all trade secrets as defined under the Illinois Trade Secrets Act or other applicable law affording protection to trade secret information. Some of this Confidential Information is also protected health information, as defined by the Health Insurance Portability and Accountability Act ( HIPAA ). Your use of information protected by HIPAA is also subject to ATI s HIPAA Privacy Policy. You recognize that this Confidential Information constitutes a valuable property of ATI, developed by ATI over a significant period of time and at substantial expense. You further acknowledge that ATI s industry is highly competitive, and that ATI would be irreparably harmed by actual or threatened disclosure or use of its Confidential Information to any competitor or outside party. Accordingly, you agree that you will not at any time during your employment with ATI or thereafter, use or disclose any Confidential Information, except as necessary and authorized in the course of your employment with ATI. You acknowledge and agree that the restrictions imposed by this Agreement are reasonable and not contrary to public policy, and that such restrictions are intended solely to safeguard the protectable interests and legitimate business needs of ATI. You further acknowledge and agree that your adherence to these restrictions will not prevent you from engaging in your chosen occupation and earning a satisfactory livelihood following the termination of your employment with the Company. Upon the termination of your employment, or sooner if requested, you will return to the Company all computer hardware, software, diskettes and other media, program codes, program documentation, contracts, proposals, plans, lists, reports, schedules, manuals, files and other documents or items which relate in any way to the business of the Company, including, without limitation, all materials that constitute, contain, or refer to any Confidential Information, including all copies thereof. ATI reserves the right to take disciplinary action, up to and including termination of employment for violations of this agreement. Your signature below indicates that you have read, understand, and accept the terms of this Agreement. 1
Acknowledgement I have read and fully understand this policy. My signature below confirms my understanding of the above Confidentiality Agreement. Violations of this policy may result in discipline up to and including termination of employment. Employee PRINT NAME Employee SIGNATURE Witness CC: Personnel File S:\Human Resource\FORMS\ATI Confidentiality Agreement.DOC - attorney review 6/2006 2
Professional Appearance Standards - Clinic Clothing/ Uniforms Shoes Personal Hygiene Jewelry Hairstyling Tattoos Fingernails TOPS: CLINIC staff (clinicians, drivers, front office, rehabilitation technicians, etc.) must wear Company logo shirts. Company shirt must be tucked in. HOA will remain in HOA logo wear. PANTS: Within the Clinic, professional slacks only (black or grey dress style) are acceptable and must be worn with a belt. Yoga pants, stretch pants, capri pants, cargo pants, and/or skirts are not permitted. SHOES for the following CLINIC staff (clinicians, drivers, rehabilitation technicians, etc.). Should be professional and kept in good condition. Loafer style shoes are acceptable. Tennis, athletic appearance shoes or open-toe shoes are not permitted.* First Director standards shall be discussed directly with First Directors. SHOES for front office staff should be professional and kept in good condition: Open-toe and loafer style shoes are permitted. Flip-flops, any shoes that go between the toes, tennis shoes or athletic appearance shoes are not permitted.* *Please see Regional Director on exceptions for medical reason(s). Our work involves close contact with patients and co-workers and therefore, employees are required to use good judgment when personal hygiene is concerned. Gum chewing is not permitted during any patient or visitor contact, either in person or on the phone. Only mild fragrances or perfumes are to be worn. For women only, no more than two piercings per ear. Oversized earrings & jewelry are not permitted. Facial piercings* are not permitted by any staff. *Please see Human Resources on exceptions for medical or religious reason(s). Extreme, asymmetrical or bi-level styles are not permitted. Hair color should be natural looking, and if color is changed, it should be maintained. Visible tattoos are not permitted. The use of bandages/make-up to conceal a visible tattoo is permitted in the event a tattoo is acquired prior to first day of employment at the Company. For women only, if polish is used, it should be a complimentary color. Multi-colored painting is not permitted. Men may only wear clear nail polish, if chosen to do so. Page 1 of 2
Facial Hair Make-Up Personal Pagers/ Cellular Phones Mustaches, beards, and goatees are permitted. Facial hair should be neatly trimmed daily. Women only are welcome to wear make-up to the extent to which it enhances natural features and to create a fresh, natural appearance. When engaging with patients, personal pagers or cell phones are not to be worn. Company provided cell phones or pagers should be in the off or vibrate position when engaged with patients as appropriate. *Where a bona fide religious tenet conflicts with any of the above standards, a request for a reasonable accommodation that does not impose an undue hardship on the Company shall be considered. Acknowledgement I have read and fully understand the above Professional Appearance Standards - Clinic set forth by the Company. I understand that, at times, the Company shall modify the policies and this policy. I understand that failure to comply with the above grooming standards shall result in disciplinary action up to and including termination of employment. My signature below confirms my understanding of the above Professional Appearance Standards. Employee PRINT NAME Employee SIGNATURE Witness CC: Personnel File Page 2 of 2
PHOTO and ELECTRONIC COMMUNICATIONSWAIVER & RELEASE FORM I hereby authorize ATI Holdings, Inc., ATI Holdings, LLC, Athletic & Therapeutic Institute of Naperville LLC, the ATI Foundation and their affiliated companies, predecessors, successors, and all of their present and former officers, directors, employees, agents, representatives and assigns (hereinafter referred to as ATI ) to use, release or publish photographic pictures of me, or in which I may be included, for promotional purposes. My authorization extends to photographic pictures in any or all media now or hereafter known, including but not limited to electronic images (i.e.,.jpeg), digital images, print, video or film. I also consent to the use of any printed matter in conjunction therewith, including my name or any statements that I have written in the form of a testimonial (altogether, images and text, the Information ). I understand that the Information published will be generally available to the public, and to the extent it is used on the Internet, may be viewed by anyone around the world. I release ATI from any liability resulting from or connected with the release or publication of the Information as described herein. I shall not hold ATI liable or responsible for unauthorized access or use of the Information. By offering my consent, I agree to waive any and all claims for damages, including attorney s fees, arising from the release or publication of the Information. Additionally, I waive any right to royalties or other compensation arising or related to the use of the Information. I understand and acknowledge that I received, and/or may request at any time, a copy of ATI s HIPAA Notice of Privacy Practices describing any other rights I may have with respect to the Information. I further understand that medical treatment, payment, enrollment or eligibility for benefits may not be withheld from me based on failure to sign this authorization. I understand that the Information used or disclosed pursuant to this authorization may be subject to re-disclosure by any recipient and will no longer be protected by ATI s privacy policies. I understand that I retain the right to revoke this authorization in writing at any time by delivery of a written notice to the ATI and that such revocation shall be effective for future uses and disclosures, but such revocation shall not be effective for Information already used or disclosed. I understand that written revocation of this authorization must be sent to ATI. I have read the above authorization, release and agreement, prior to its execution, and I am fully familiar with the contents thereof. This release shall be binding upon me and, or, parent/legal guardian, heirs, legal representatives and assigns. This authorization shall expire 6 years from the date signed below. 1
Name: Age*: Signature: *If under the age of eighteen (18), the release needs to be signed by a parent or legal guardian. : Name of Parent or Legal Guardian: Signature of Parent or Legal Guardian: _ : PHOTO WAIVER & RELEASE FORM OPT OUT I am choosing to opt out of this photo waiver. Name: Age*: Signature: *If under the age of eighteen (18), the release needs to be signed by a parent or legal guardian. : Name of Parent or Legal Guardian: Signature of Parent or Legal Guardian: _ : 2