Observation Application

⮜ Return to Clinical Experience

Thank you for your interest in observing at Stormont Vail Health. Complete all sections of this application. Upload all required documents before submitting your application. We cannot schedule an observation until we receive all required documents. Submit requested observation dates at least two weeks in advance to allow time for processing. Missing information or documents will delay processing.

If you want to shadow a specific provider or unit, include the provider or unit name in your application.

Observations are limited to 24 total hours per unit. Observation approval is valid for three months. Complete all approved shadowing hours, up to 24 hours, during that three-month period.

Applicants must be at least 16 years old.

Comments

This field is for validation purposes and should be left unchanged.

Full Name(Required)

Address(Required)

Phone(Required)

Email(Required)

Date of Birth(Required)

School/Company

School/Company Address

School/Company Contact

Contact Phone Number

Field and State of Licensure (if applicable)

Requested Area(s) of Observation:(Required)

Reason for Observation:(Required)

Preferred Location(s)(Required)

Topeka

Emporia

Manhattan

Junction City

Other

Select all that apply

Type in location

Requested date(s):(Required)

Personal Health Insurance:(Required)

Upload a clear image or scanned copy of the front and back of your personal health insurance card.

Accepted file types: jpg, jpeg, png, gif, pdf, Max. file size: 10 MB.

Professional Liability Insurance:

Licensed applicants may upload a copy of their Certificate of Insurance.

Accepted file types: jpg, jpeg, png, gif, pdf, Max. file size: 10 MB.

Tuberculosis (TB) Test Result:(Required)

Upload documentation of a negative TB test result dated within the past 12 months. A QuantiFERON blood test or TB skin test is acceptable. For a skin test, the documentation must include the facility or provider, plant date, read date, and result in millimeters (mm).

Accepted file types: jpg, jpeg, png, gif, pdf, Max. file size: 10 MB.

Seasonal Influenza Vaccination:(Required)

Upload documentation of your current seasonal influenza vaccination.

Note: This documentation is required from October through March. Outside this period, upload your most recent vaccination record for review.

Accepted file types: jpg, jpeg, png, gif, pdf, Max. file size: 10 MB.

Agreement

By checking this box you are agreeing to follow HIPAA and keep information about our patients confidential. This is any information that may identify the patient or is related to their condition, treatment, or payment for services.

Please review the HIPAA Guidelines at the link provided here: https://www.hhs.gov/hipaa/index.html

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Observation Application