Common Contracts
2 similar Harborview Medical Center contracts
APPLICATION AND AGREEMENT FOR OBSERVATIONAL ACTIVITIES Please fill out completely. Incomplete forms cannot be processed.Harborview Medical Center • September 8th, 2017
OBSERVER INFORMATION Name: Day Phone: Address: Evening Phone: City: State: Zip: Email: Medical area of interest: School (if applicable): Grade or Degree level: I am 18 years of age or older Yes No, I am years old Current Job Title (if applicable): Company Name: Phone Number: Have you ever been convicted of a felony? Yes No Have you ever had a license revoked or denied? Yes NoPlease include state or federal photo ID with your application. I have made specific arrangements with a Harborview physician who has agreed to have me observe. Physician Name: Title: Dept/Unit: Phone: Coordinator’s Contact Information (if applicable)Name: Email: Phone: Reason for requesting observational activities:I am a medical professional (e.g. physician, ARNP, PA, Nurse, Medic) seeking additional experience.I am a medical professional (e.g. physician, ARNP, PA, Nurse, Medic) seeking to observe at the invitation of for the purpose of mutual sharing of clinical, teaching and / or research.I am employed by a
APPLICATION AND AGREEMENT FOR OBSERVATIONAL ACTIVITIES Please fill out completely. Incomplete forms cannot be processed.Harborview Medical Center • September 8th, 2017
OBSERVER INFORMATION Name: Day Phone: Address: Evening Phone: City: State: Zip: Email: Medical area of interest: School (if applicable): Grade or Degree level: I am 18 years of age or older Yes No, I am years old Current Job Title (if applicable): Company Name: Phone Number: Have you ever been convicted of a felony? Yes No Have you ever had a license revoked or denied? Yes NoPlease include state or federal photo ID with your application. I have made specific arrangements with a Harborview physician who has agreed to have me observe. Physician Name: Title: Dept/Unit: Phone: Coordinator’s Contact Information (if applicable)Name: Email: Phone: Reason for requesting observational activities:I am a medical professional (e.g. physician, ARNP, PA, Nurse, Medic) seeking additional experience.I am a medical professional (e.g. physician, ARNP, PA, Nurse, Medic) seeking to observe at the invitation of for the purpose of mutual sharing of clinical, teaching and / or research.I am employed by a
