Pediatric Hematology/Oncology

Request for Visiting Observer

Now that you have read our website and have the required documents ready (preferably PDF), please move forward with your visit by completing this survey

Visiting Observer:

A visitor to SHC and/or LPCH who will be watching patient care and administrative functions for medical or professional education, or training

**Request MUST be received a minimum of six (6) weeks prior to start date**

Please complete the following:

Full Name*

Email Address:*

Phone Number:*

Date of Birth:*

Full Name of Faculty Host:*

Date(s) of Prospective Visit:*

Please note, visit must not exceed six (6) months

How many days a week will you be observing?*

Are you enrolled in an education program?*

Please only answer "Yes" if you are enrolled in an education program resulting in a certificate or degree from an accredited college or university.

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Name of education program*

Please enter the name of the certificate or degree granting program and the name of the accredited college or university.

Are you a Stanford employee?*

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You are employed by:

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Are you currently volunteering at Stanford?*

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You currently volunteering at:

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Are you a member of the media or a publication?*

This includes any scientific or academic journals.

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What type(s) of media do you represent?*

Please include as much information as possible below and, if applicable, links to any publications by the VO.

VO in the media or a publication attestation:*

VO understands that he or she is NOT permitted to publish anything about his/her visiting observation experience at SHC.

Are you employed by drug or medical device company?*

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What company are you affiliated with?*

Please include as much information as possible, including your role at the pharmaceutical/medical device company, and include links to the company website.

Select the option that best describes you:*

Please make the selection that is the most applicable. Only one selection is permitted. If selecting "Other," then provide additional information in the appropriate text box.

International Physician coming to observe a procedure(s)

Domestic physician or healthcare professional coming to observe patient care for education or health care operations

Medical Student coming to observe for educational purposes

Pre-Med/Undergraduate student

High School Student

Community members or other wishing to tour the facility

Community member interested in learning about specific health care career

Visitor is part of a SU/SoM class that has a clinical observation component

Other

Additional information about VO's role*

Please include additional information, such as your professional title(s), credential(s), etc.

Are you enrolled at SU School of Medicine (SOM)?*

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SU SOM Medical Student's school email address:*

Are you interested in a Visiting Clerkship instead?*

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SU School of Medicine Visiting Clerkship

There are three (3) Visiting Clerkship options available. Please direct the VO to visit the SU School of Medicine Visiting Clerkship website to learn more about the options available: https://med.stanford.edu/clerkships.html

There is no need to continue completing this VO Request Form, as the Visiting Clerkship office will now assist the prospective visitor. Please reach out to the contacts on the Visiting Clerkship website (above) for further instructions.

File Upload at end of form (Non-SU Medical Student)

Upload a copy of your official transcripts or letter of enrollment/good standing from your medical school.

Facility Tour (public vs. clinical areas)*

Will the tour include passage into or through patient care areas or where patients may receive care?

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Additional information about SU/SoM course:*

Include course title, course number, course/program description, and, if possible, links to the course/program on the SU website.

Additional information about your role*

Please include additional information, such as VO's professional title(s), credential(s), etc.

Briefly describe your intended purpose for observing here at SCH/SHC:*

Varicella (Chickenpox) record received is:*

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Mumps record received is:*

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Measles record received is:*

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Rubella record received is:*

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Flu Vaccine (if visit is Nov 1 - April 30):

Is Tuberculosis Screening Questionnaire received?*

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TB test record (less than 1 year old) received is:*

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Is VO fully vaccinated/boosted for COVID-19?*

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Is VO requesting accommodation for any vaccines?*

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If so, please summarize details of request below:

Please click each item to confirm you have read and understand each of the following:

Code of Conduct: I certify I have read and understand the code of conduct. I certify I have read and understand the cod of conduct. Code of Conduct

Observership Statement: I understand that this is an observership and is NOT part of any formal education process: Observership Statement

Observership Reminders: I understand and agree to comply with the following statements:

The visiting observer shall not:
Provide any treatment of care
Conduct any administrative work or support
Access any PHI, including EMR
Use any information that you exposed to for research related purposes
Use the experience as a visiting observer on a resume, CV, etc...

I have read the Code of Conduct:*

By clicking below. You acknowledge that you have read the Code of Conduct.

I have read and understand the Observership Statement:*

By Clicking below. You acknowledge that you have read and understand the Observership Statement.

Please upload your vaccination/transcript records*

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