Research 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 research observership application process.

* 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 Email

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?

Are you a current University of Miami (undergraduate) student?

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.

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.

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Observer Program Application Signature