Observership » Department of Pediatrics » College of Medicine

Observer Information

Name*

First Last

Email*

Current Occupation:*

Name of current institution, school, or employer*

Address of current institution, school, or employer*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Type of Observers*

Visiting Scholar (clinical or otherwise)

Faculty/staff applicant (usually staying for a few days)

Student applicant

Other:

Other*

Area(s) to Observe*

Teaching Hospital

E.R.

O.R.

Other (clinic/institute name):

Other*

Anticipated Date Ranges
Please include three different data ranges. Observerships can last for a maximum of 120 days. This form must be submitted at least 2 weeks before a requested observership start date.

Start Date*

End Date*

Start Date*

End Date*

Start Date*

End Date*

Reason(s) for Observation*

Visiting Health Care Provider

Career Planning

Required Course Work (describe below)

Other:

Other*

Observer Statement of Interest*

Please describe your reason(s) for requesting to observe care and how this experience will enhance your clinical knowledge.

Signature*

Sponsoring Faculty Information

Name*

First Last

Title*

Phone*

College*

Department*

Division*

Observership Request

Observer Information

Sponsoring Faculty Information