New Visiting Observer Form

Please complete the form to initiate the process of inviting a Visiting Observer.

For additional information, please review the Visiting Observer Packet.

Who is eligible to participate in the Visiting Observer program?

The following categories are generally allowed under the Visiting Observer policy:

International Physicians interested in observing procedures
International Professionals interested in observing procedures for educational purposes
Domestic physicians or healthcare professionals interested in observing care for education or healthcare operations
Medical Students currently enrolled in a non-Stanford medical school that are interested in observing care (this excludes medical students here for training related to a clerkship or externship)
Students from Stanford or another domestic University
Pre-med/Undergraduate student
High School Students that are age 18 or over
DO students - permitted to observe in all clinical areas including O.R.
Clinical residents and fellows - NOT FOR EDUCATIONAL CREDIT

Important Note about Observership:

Visiting Observers, under the supervision of their host, can observe patient care, procedures, or the use of special equipment at SHC. Visiting Observers cannot participate in patient care, conduct any administrative work, access any protected health information, or use any of the information that he or she is exposed to for research purposes. Visiting Observers cannot take any pictures, audio, or recordings of patients.
Visiting observers can sit in during sign out and may be shown cases (as long as the host is present), but visiting observers are not allowed to be given any cases to look at independently or handle any information that has any patient identifiers. During downtime visiting observers can review textbooks or other study materials.
Visiting Observers are not allowed to use the visiting observer experience on their resume. You attest to this limitation in the agreement you sign as part of the clearance process. However, a VO may ask their host to write a letter of recommendation, but the letter cannot be on Stanford letterhead.

Your position:

Sponsoring "Host" Faculty:

Sponsoring "Host" Faculty's Speciality:

Prospective Visiting Observer's Name:

Prospective Visiting Observer's Last Name:

Prospective Visiting Observer's Email:

Length of visit:

Desired Start Date:

Note: All visiting observers are limited to 30 days total in any given 12-month period. One day equals any amount of time spent physically on-site per day. Half days (or even 1 hour) spent on site are considered one (1) day. The office does not permit visiting observations longer than 30 consecutive calendar days.

mm/dd/yyyy

Desired End Date:

mm/dd/yyyy

What Specialty would the prospective visiting observer like to observe?

Each Specialty requires a faculty member willing to host

Brief justification on reasoning to observe:

Who, What, Where:

Please provide 2-3 sentences about the service, location, and if any other faculty will work with the visiting observer.

Which category does the prospective visiting observer fall under?

What is the prospective visiting observer's professional title?

Institution

Prospective Visiting Observer's Date of Birth

mm/dd/yyyy

Is the prospective visiting observer over the age of 18?

Is the prospective visiting observer part of any formal education program that would result in a certificate or degree from Stanford University?

Is the prospective visiting observer employed by one of Stanfords hospitals?

Is the prospective visiting observer currently volunteering at any SHC facility?

Is the prospective visiting observer a member of the media or on staff at any publication?

Is the prospective visiting observer employed by a pharmaceutical or medical device company?

Please upload ALL required documents: NO PARTIAL UPLOADS WILL BE ACCEPTED

CV
Photograph
Immunizations: Varicella (positive titer or 2 vaccines), MMR (positive titer or 2 vaccines), TB (within 1 year of visit, one QuantiFERON or two Tuberculin Skin Test (see two-step process link below), Flu vaccine (if visit occurs Aug 1 - May 31 must be within the same season), COVID. Needs to be in English. Proof of Dates and Results is REQUIRED
Official Medical School Transcript
TB two-step process https://www.cdc.gov/tb-healthcare-settings/hcp/screening-testing/baseline-testing.html?CDC_AAref_Val=https://www.cdc.gov/tb/topic/testing/healthcareworkers.htm

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