Visiting Observer Intake Form

Visiting Observer Intake Form

Please use this form to request an observership with a faculty member at Stanford University's Division of Plastic & Reconstructive Surgery.

Please Note

Submission of this form does not guarantee placement. Before filling out this form please reach out to the faculty you'd like to observe to gain approval, you will need to attach the approval email at the end of this form.

Are you at least 18 years old?*

Yes

Ineligible

You must 18 years old to participate in the Stanford Health Care visiting observership program.

Education Level*

Select or enter value

Please enter Date of Birth*

Your Email Address*

Please enter the best email to contact you at.

Your First Name:*

Your Last Name:*

Briefly describe your intent, and what you would like to gain from your visit.*

Requested Start Date*

PLEASE NOTE: The duration of an observership is max 30 calendar days beginning at the requested start date. I.e. If your start date is January 1 your end date must be anytime before January 31.

Requested End Date

Please select a date at least 6 weeks from the today.

Home Institution Location*

Select or enter value

Street Address, City, Zip, Country*

Phone Number*

Faculty You Are Requesting to Observe:*

Select

Has the faculty already agreed to host your visit for the dates requested?*

Yes

Are you currently enrolled in a hospital sanctioned course program?*

ex: SIMS, Clerkship

Yes

Hospital Program Name:*

SIMS Program

Clerkship Program

Required Medical Records

Proof of the following vaccines and/or test results will be REQUIRED for Clearance to Observe in Operating Rooms and Clinics. These records must be submitted in a timely manner and at the very latest two weeks prior to the start date of observation.

Acceptable proof is a copy of official medical records with your name, date of birth, official stamp or doctor's logo, date of vaccine or date of test and test results.

All non-English records must be accompanied by a translation. The translation does not have to be “official”.

COVID-19

Evidence of full vaccination: 14 days after 2nd dose mRNA or 1 dose vector (approved for Emergency Use Authorization in the USA) and a booster vaccine (as of January 24, 2022)

Varicella (Chickenpox)

Evidence of Positive Titer or of 2 Varicella vaccines. History of the disease is NOT acceptable.

Measles

Evidence of Positive Titer or of 2 MMR or Measles vaccines

Mumps

Evidence of Positive Titer or of 2 MMR or Mumps vaccines

Rubella

Evidence of Positive Titer or of 2 MMR or Rubella vaccines

Tuberculosis

ONE of the following within 365 days of start date (even if you have received a TB vaccine)

TB Skin Test: Must be within 10 months of observation start date. Evidence of an injection, a reading and the result

Quantiferon Test (QFT): Evidence of test

Chest x-ray: Copy of doctor's reading of results

Influenza (IF observing from November 1 to April 30)

Evidence of flu vaccine for CURRENT flu season (dated Sept 1 or later)

Select YES / NO. If NO, select another date.*

Select or enter value

REQUIRED FILES:*

Please upload (all documents must be in English or translated):

Your current CV
Copy of your Passport
College Transcript if you are a medical student (or letter from institution showing proof of enrollment)
Copy of approval email from faculty you are requesting to observe

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