Tri-Valley Visiting Observer Request Form

Please provide the following information regarding your request.

Name of the prospective Visiting Observer (VO)

Is the prospective Visiting Observer over 18?

Is VO enrolled in a formal education program?

Is the VO a Stanford employee?

Is the VO currently a volunteer at Stanford?

Is the VO a member of the media or a publication?

Is VO employed by pharmaceutical/device company?

Select option that best describes the VO:

Briefly describe the VO's intended visit purpose

Host name

Host job title

Host department

Name of Host's department chair or clinic manager

Name and location where observation will occur

Will any observation occur in OR/Cath Lab/ASC?

Prospective VO will be observing care of:

Has Host department been alerted to observation?

Proposed dates and/or length of visit

Host must obtain patient authorization for visits

Host must supervise VO at all times during visit

Host must maintain visit documents for 6 years

Send me a copy of my responses