Observership Application
Demographic
First name
Last name
Address
City
State
Zip
For International Applicants, please enter address below.
Contact number
Alternate Contact number
Email address
Date of Birth
Do you have someone who has agreed to allow you to observe them?
Yes
No
Job Role Information
Job role you are requesting to observe
Name of preceptor
Email of preceptor
Requested date(s) for observership experience
You will need to find and secure your own preceptor host for observership. Please list below your desired observer experience.
The Office of Learner Affairs cannot guarantee placement with a preceptor.
Please visit CAMC.org for a list of our Providers.
Applicant Information
Name of Medical School you graduated from
Year of Graduation
Have you completed a prior observership with CAMC/Vandalia Health?
Have you completed a prior observership with CAMC/Vandalia Health?
Yes
No
Please list prior observership. Please note, learners are limited to a one-time observership experience.
What do you hope to gain from an observership experience at Charleston Area Medical Center/Vandalia Health?
Have you ever been convicted or pled guilty to a violation, even if dismissed, of any law other than a minor traffic violation?
Yes
No
If yes, list the violation and date of conviction or plea:
Health Screening Questionnaire
Have you traveled anywhere within the last 8 weeks? If so, where:
List any chronic health problems or immune disorders:
List any allergies:
Describe any chronic skin conditions or open wounds:
Have you ever had any exposure with active tuberculosis?
Yes
No
Have you had a positive TB skin test?
Yes
No
Current PPD date. (must be current within 1 year). Please submit result of PPD. ***must provide results from a physician's office***
Have you ever had chicken pox? ***must provide proof of immunity, tier, or 2 vaccinations***
Yes
No
Immunizations
All immunizations are required before approval of application. Please list immunizations for the following diseases and attached a copy of immunization records.
Measles, Mumps, Rubella (MMR)
Date Received
Date Received (Must list 2 dates)
Varivax (Chicken Pox)
Date Received
Hepatitis B
Date Received
Date Received
Polio
Date Received
Adult tDap
Date Received
Date Received
Seasonal Flu Vaccine
Date Received (required if shadowing between October through April)
Learners should avoid being in patient care areas if they have relevant contagious respiratory, gastrointestinal, or skin diseases.
By typing your name and date below, you certify that the forgoing statements are true and complete.
Please upload a copy of your immunization records
Please upload a copy of your recent drug screen
Please upload your CV
Observership Confidentiality Agreement
I acknowledge that during my observation experience at Charleston Area Medical Center/Vandalia Health
, I agree to keep all information in strict confidence and will not d
isclose or disseminate any confidential information that I may be exposed to. I understand that I
am obligated to always maintain patient confidentiality, both at the facility and when away.
I understand that all the medical information/records regarding a patient are confidential. This i
nformation will not be given to other individuals unless proper authorization is obtained. I understand
that it is not appropriate to discuss any patient’s care and treatment in public places or
with people that have not been involved in the case and does not have reason to know details of
the patient’s health care. I also agree that I will not share conversations I hold with any healthcare provider
during the course of the observation experience. I further agree that I will not take
pictures or share information on any social network website or in emails.
I understand that all patient, associate and/or organizational information, (financial and/or
clinical), retrieved from any and all computer system(s) is strictly confidential. It should not be
reproduced, transmitted, transcribed, or removed from the premises in any form.
I understand that any deviation from the above could result in legal action against the
organization and me. I further understand that any breach of confidentiality, intentional or
unintentional may result in immediate termination of my observation experience and deny any
future opportunities.
My name below certifies that all of the above confidentiality considerations have been explained to me and I was afforded the opportunity to ask questions.
Required Education
Click the radial to confirm you are aware of the required education that must be completed prior to starting. The education information and link will appear on the next screen
Yes, I am aware of the education requirement.
reCAPTCHA helps prevent automated form spam.
The submit button will be disabled until you complete the CAPTCHA.
