CommUnityCare Observership Form

CommUnityCare Observership Form

Please complete this form and upload all required documentation for consideration of an observership experience within CommUnityCare clinics.

The application is a 3-step process.

Step 1: Download and complete the required documents.

Shadowing Agreement Form
Code of Conduct
ID Badge Agreement
Professional Photo
Background Check (within the last 6 months) - Instructions
Proof of Immunizations - List of Required Immunizations

Alternatively, students who have completed #5 & #6 with their school can provide an attestation letter in place of these.

Step 2: Review the required compliance training modules linked here:

Step 3: Complete the rest of this form along with the required documents.

Please note that the Department of Education and Research will evaluate each application on a case-by-case basis to determine applicants appropriately. A completed form does not guarantee placement. Limited to one application per term, per student. Be sure to send a copy to yourself for your own records.

For any questions, please contact Educationandresearch@communitycaretx.org

Today's Date*

Preferred Term*

Select or enter value

First Name*

Last Name*

Email Address*

Phone Number*

Date of Birth*

mm/dd/yyyy

Ethnicity

Select or enter value

School/University*

Who would you like to observe?*

Nurse

RDA

RDH

Dentist

Dental Hygienist

Dental Assistant

Pharmacy

Other (please list)

Major or Field of Study*

Current undergraduate or anticipated major or field of study. (Example: BS Public Health)

CUC Capstone or Practicum Support

Select or enter value

Anticipated Graduation

Preferred Clinic Placement Site*

Select or enter value

Preferred Start Date*

Preferred End Date*

Preferred Observation Hours*

Please note CommUnityCare permits a maximum of 24 hours for shadowing placements.

Full name of Community Care preceptor/sponsor.

Please leave blank if unknown

Has sponsor agreed to precept the student?

Yes

Total Hours Requested*

For shadowing opportunities, a maximum of 24 hours (3 business days) is allotted

Letter of Intent*

In 3-5 sentences, please explain why you are interested in an observership experience with CommUnityCare.

Required Documents*

Please upload the following documents in this section. Be sure to name the file in the format Title_FullName (Example: IDBadgeAgreement_JohnSmith).

Code of Conduct
ID Badge Agreement
Shadowing agreement
Professional Photo (of the student from shoulders up)
Attestation Letter (if applicable)

Drag and drop files here or

Background Check & Immunizations

Please check this box if you will be providing your own background check and immunization records instead of an attestation letter.

A member from our team will be in touch with you to confirm your placement status and where to send these items once obtained.

For questions on these items please contact Educationandresearch@communitycaretx.org

Required Modules*

I, the student, have reviewed and completed the following required modules:

Blood Borne Pathogens

Compliance

Culture Competency

Hand Hygiene

HIPAA

Social Determinants of Health

CUC Emergency Codes

Please initial below confirming completion.

Acknowledgement*

I, the student, will not have any EHR access.

I, the student, am required to inform the Department of Education and Research of any schedule changes that may arise during my clinical rotation.

I, the student, will only enter through the front entrance when entering clinic.

I, the student, will ensure to wear the CommUnityCare badge given to me upon starting at all times and will return it upon completion of my rotation.

IMPORTANT NOTE: If I, the student, do not have approval from the Education and Research department, I will NOT report to clinic.

If I, the student, am a CommUnityCare employee I will not complete any student duties during work hours and must be off the clock.

By signing this Electronic CommUnityCare Observership Form, I, the student, understand the student expectations and guidelines above and I agree that my electronic signature is equivalent to my handwritten signature.

Signature:

Clinical Coordinator Name from your School

Clinical Coordinator Email

Send me a copy of my responses

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