Student Observation Form for Individuals

Student Observation Form for Individuals

About this form:

Please complete the form below to be contacted by Good Shepherd Learns. Required fields are indicated with a red asterisk (*).

*Note: You cannot Save & reopen the form. Before starting to fill out the form, please have the following ready to upload in the space provided at the bottom of this form.

Student Observation document completed and signed
Proof of Covid Vaccine, if received - no longer mandatory
Proof of Flu Vaccine, if placement is between September and May

About Good Shepherd's Student Observation Program:

OT, PT, and SLP observation opportunities are held at Good Shepherd at select sites and in a variety of settings to facilitate safe and optimal learning experiences for our students, patients, and staff.

Observation experiences are scheduled on a first come, first serve basis, and we all required documents need to be submitted prior to your scheduled start date.

Criteria for observation:

Complete only up to 24 hours of observation at Good Shepherd (for >24 hours, please contact the Volunteer Office)
Must be 16 years of age or older
Provide proof of Covid (if received) and Flu vaccinations (if between September and May, annually)
Complete, sign, and return Student Observation documents (with parental consent when applicable)
Strictly observational purposes with no hands-on patient contact
Business casual attire must be worn

Observation at our Inpatient Pediatrics Unit is by request only, at this time. Please email learn@gsrh.org to request shifts at this location.

If you have an interest in observing a discipline other than OT, PT, or SLP - please email us.

For questions, please email Learn@gsrh.org.

Thank you!

Please tell us a little about yourself.

Name (First & Last)*

Email*

Your email will be used as the primary means of communication. Please make sure you enter it correctly.

Are you under 18 years of age?*

If yes, you will need to provide your Parent/Guardian's Name and Email Address to co-sign your documents.

Yes

Parent/Guardian Name*

Parent/Guardian Email*

Phone Number

Phone

School

Select

School Coordinator Name

School Coordinator Email

If you are in touch with a Good Shepherd associate, please list their name here.

Please list the Good Shepherd employee's email address.

Observation Preferences

Though we cannot meet all requests, we do our best to accommodate your preferences while prioritizing a safe and meaningful learning, work, and care environment.

Please select the discipline(s) you would like to observe, if they are available.*

*Subject to availability*

For a list of sites that offer Speech Therapy, please email learn@gsrh.org

Select

Discipline if not listed*

Are you required to only observe this discipline as part of your graduate school admission requirements?*

(Please note that we cannot guarantee the ability to accommodate discipline-specific observation requests. If you would like to explore other options for completing discipline-specific clinic hours as part of a grad school admission requirement, please email learn@gsrh.org)

Yes

What is the earliest date you could observe?*

Observation experiences are scheduled on a first come, first serve basis, and we require submission of all required documents at least 14 days prior to your scheduled start date.

What is the last date you could observe?*

How many total hours would you like to observe?*

Good Shepherd offers up to 24 hours of student observation. For options to complete additional hours, please email learn@gsrh.org.

Additional Comments

Please select the documents you will be uploading on this form.*

Student Observation Packet

COVID Vaccination

Flu Vaccination

Upload the Required Documents here.*

Please complete: Student Observation Packet

(requires parent/guardian signature if under 18 years old)

If applicable, please also include:

Proof of Covid Vaccine, if received - no longer mandatory
Proof of Flu Vaccine, if placement is between September and May (flu season)

Please note: You will not be scheduled for observation until we receive this completed form and all required documents.

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