Prohealth Care, Inc
10/2013
ProHealth Care
Request for Observation
All information requested on this form must be complete, and submitted to the Center for Learning & Innovation before an observation experience may be scheduled. Fulfillment of this request is contingent upon approval from the department manager. We reserve the right to deny requests. (Please allow at least two weeks to process your request.)
Observer Name (Please Print): ______Email: ______
Address: ______City: ______Zip: ______
Phone: ______School/ Organization: ______Age (if under age 18): ______
Reason for Observation Request: ______
Desired Observation Date(s): ______# of hours requested: ______
Department & Role to be Observed: ______
Facility preferred: Waukesha Memorial Hospital ______Oconomowoc Memorial Hospital ______
Other ProHealth Care site (please state): ______
ProHealth Care Employee Sponsor or Physician (if known): ______Phone: ______
Immunization Record: Requests will NOT be considered without copies of complete immunization data.
Date Live MMR ______OR Date Rubella titre indicating immunity ______
Date Varicella ______OR Date of Chickenpox or positive Varicella titre indicating immunity ______
Date TB Skin Test ______Results ______(Must be within the last 12 months)
Date Seasonal Flu Vaccine ______
Life Safety Requirements: (Please note – requests will not be considered without completing this requirement)
I have read and understand the information provided to me on the Life Safety Code Sheet (Separate form).
Observer signature: ______Date: ______
Confidentiality Agreement: I understand that my request to observe at a ProHealth Care site may include access to information regarding patients and their care, which I must protect and keep confidential.
Protected information can be obtained through observation; conversation with a patient, family member, physician, or other caregiver; and/or from the patient’s written or electronic medical records. Information that is protected includes, but is not limited to:
Ø Patient is or has been receiving care in one of our facilities.
Ø The patient’s history and diagnosis.
Ø The care the patient does or does not receive.
Ø The patient’s ability to pay.
Ø The patient’s response to treatment.
Ø Information about the patient’s family.
I agree to safeguard, and will not share any of the above information. By signing the attached agreement, I agree to knowingly and voluntarily maintain the utmost confidentiality as it relates to any patient information. (Please note – you must also read and sign the enclosed Confidentiality Agreement)
Observer signature: ______Date: ______
Parental/Guardian Consent (if observer under 18 years of age):
Name: ______Relationship: ______
Please return this form to: Monica Erdmann, PHC: Center For Learning & Innovation
725 American Avenue
Waukesha, Wisconsin 53188
Questions: please call 262-928-2909 Fax number : 262-928-2092
Date of observation ______Department /Role Observed ______