Student/Observer Application

Clinical/Observation Request Form

DEMOGRAPHIC INFORMATION

* Required Field

First Name_*

Last Name_*

Middle Initial

Permanent Home Address_*

Address Line 2 (Ex. Apt #/Letter, Suite, etc.)_*

City_*

State_*

Zip_*

DOB_*

Cell Phone_*

Email Address_*

EMERGENCY CONTACT

First Name_*

Last Name_*

Relationship_*

Phone Number_*

REQUEST PLACEMENT DETAILS

Requested Location for clinical/observation request_*

Request Type_*

Setting Request_*

Date Range of Request_*

Were you referred by someone who currently works at ProgressiveHealth Company?_* Yes No

If "yes", name of employee you spoke with:_*

EDUCATION

What university do you currently attend?_*

What year are you currently in?_*

Program/Discipline_*

Who is your current university clinical instructor/advisor?_* First and last name

Instructor/Advisor Phone_*

Instructor/Advisor Email_*

HEALTH/MEDICAL SCREENING

Do you have a past history of TB?_* Yes No

Have you ever hada positive TB skin test?_* Yes No

Latex Allergies?_* Yes No

Other Allergies: (please list)_*

Do you have a medical condition that could be a safety hazard to you or others?_* Yes No

If yes, explain the nature of the medical condition:_*

Do you have any contagious diseases?_* Yes No

If yes, explain the nature and duration of the illness:_*

ACKNOWLEDGEMENTS

PLEASE NOTE: ProgressiveHealth reserves the right to terminate the observational experience of any person who shows signs of communicable disease. If you are suffering from a cold, flu, fever, stomach virus or other indicator of communicable illness, PLEASE CANCEL YOUR OBSERVATION AND RESCHEDULE.

ProgressiveHealth reserves the right to deny any application or to terminate the observational experience of anyone who provides inaccurate application information or fails to observe ProgressiveHealth standards and policies.

I understand if I knowingly have an infectious illness, fever, cough I will refrain from visiting until at which time my symptoms have improved and I am no longer infectious. I hereby certify the above information is true and correct to the best of my knowledge.

First Name

Last Name

Date

Clear

Signature

To sign:
Computer: Place mouse cursor in the box below. Click and drag the cursor, spelling your name.
Tablet/Phone: Use your finger to draw your name.