Clinical Observership Application

Personal Information

* First Name

Middle Name

* Last Name

Preferred First Name

* Date of Birth

Current Address:

* Street

* City

State

* Zip Code

Contact Information:

* Cell Phone

Home Phone

Work Phone

* E-mail address:

Citizenship Information:

Citizenship Status

Emergency Contacts

* Name

* Cellular Number

* Relationship to you

Observership Information

Please note that a sponsor must be identified before you start the clinical obervership application process. All requests must be initiated at least 3 weeks in advance. Applications submitted with less than 3 weeks notice will be rejected.

* Start Date

* End Date

*Applications are limited to a maximum duration of 12 weeks; those exceeding this limit will be rejected.

Where will you be observing?

* Please specify department:

Please select the facility you will be observing at

* Please specify facility/location:

Sponsor Information:

Title

* UHealth Sponsor's Full Name

* UHealth Sponsor's E-mail

About this observership:

* Reason for observership

How did you learn about our UHealth's Observership Program? (check all that apply)

Faculty

Staff

School

Reputation

Referral

Other

* Please specify

Have you ever observed at UHealth?

Affiliation Information:

Are you a current or previous employee of UHealth?

Are you a current student of University of Miami Miller School of Medicine?

Do you have any relatives employed by UHealth?

Education

Highest level of education completed

* College Attended

Are you a current student?

* College/University Name

* Degree/Major

Observers Attestation and Signature

I agree to abide by the rules and regulations of the University of Miami Health System Observership program, as outlined in the Clinical Observership Program Handbook (click to download).

My name below will stand as my signature, confirming the completeness and accuracy of the information I provided above, and will carry the same force and effect as if it were signed and affixed by my hand.

I agree that this information may be verified by UHealth staff.

I understand that any misrepresentation of information constitutes cause for separation or termination from the Opservership Program.

* Observer's Full Name

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Observer Program Application Signature