UCSF Student Observer Program Intake Form

UCSF Student Observer Program Intake Form

This form is for the UCSF Radiology Observation Program. Participants must be 18 years of age or older. Please complete all sections of the form. Use the tabs below to navigate through the application. When finished, click the “Submit” button at the bottom of the form to complete your submission.
Which job observation are you currently looking for. Not all programs are accepting student observers. Note: Select only one.

Diagnostic Radiology (X-rays) (needs prior approval and acceptance into the observation)Ultrasound/Sonography-- needs prior approvalNuclear Medicine--- needs prior approvalComputer Tomography (not offered at this time)Mammography (not offered at this time)
Your Name*

First NameLast Name
Email*
example@example.com
Have you already volunteered/observed in a radiology department to satisfy the school program's requirement? If so, which hospital>*
Have you completed course work in Human Anatomy and Physiology?*

YesNoOther
Priority will be given to students who have complete courses in Human Anantomy and Physiology.

Rationale: When you follow a certified radiologic technologists, you need to know which part of the body we are taking pictures of. You need to know the language we use. For example, instead of collar bone, we use the word clavicle. Medicine is a language on its own, and if you don't know the language, you will have a hard time understanding when we talk.
- UCSF Diagnostic Radiology Observation Program
  The UCSF Diagnostic Radiology Observation Program supports students in fulfilling observation requirements for radiologic technology programs. Many programs, including City College of San Francisco (CCSF), require approximately 40 hours of observation under a licensed radiologic technologist. Students are responsible for confirming and meeting the specific requirements of their academic program. UCSF does not verify program-specific requirements.
  
  Program Guidelines
  This program is strictly observational. Observers may not participate in patient care, operate equipment, or assist radiologic technologists in any capacity.
  
  All observation hours must be completed within 10 working days, in accordance with UCSF Human Resources policy.
  
  Locations and Hours
  Observers are assigned based on availability and may not select their preferred location.
  
  Mission Bay: Mondays & Wednesdays, 9:00 AM–3:00 PM
  Orthopedic Institute: Tuesdays & Thursdays, 9:00 AM–3:00 PM
  Parnassus Heights (Moffitt–Long): Monday–Friday, 4:00 PM–9:00 PM
  (No weekends or holidays)
  Observation Areas
  Availability varies by location.
  - Inpatient portable imaging
  - Inpatient and outpatient general diagnostic X-ray
  - Emergency Department
  - Operating Room*
  - Computed Tomography (CT)*
    *Not available at all sites.
  Observer Engagement
  The quality of the observation experience depends on the observer’s motivation and engagement. Those who actively observe and seek to learn will gain meaningful insight into the field of diagnostic radiology.
- Vaccination Requirements – UCSF Medical Center
  If you are accepted into the UCSF Radiology Observation Program, you are required to complete all UCSF immunization requirements listed below. It is strongly recommended that you complete these requirements through your personal healthcare provider.
  
  You are responsible for ensuring that all vaccination requirements are met before submitting your records. Submitting incomplete or outdated records, or discovering missing vaccinations after submission, may delay your start date. Please contact your healthcare provider directly with any questions regarding immunizations.
  
  Required Immunizations
  Measles, Mumps, and Rubella (MMR)
  Proof of two vaccinations or a positive blood titer
  Varicella (Chickenpox)
  Proof of two vaccinations or a positive blood titer
  Tetanus, Diphtheria, and Pertussis (Tdap)
  Up-to-date vaccination within the last 10 years
  COVID-19 Vaccination
  Participants must be up to date with all required COVID-19 vaccinations.
  
  Effective March 1, 2024, students, learners, and staff must have received the current COVID-19 vaccination (Monovalent). UCSF will also accept the following vaccines as equivalent:
  
  Moderna SARS-CoV-2 (Spikevax)
  Pfizer SARS-CoV-2 (Comirnaty)
  Novavax
  Any COVID-19 vaccine administered on or after September 1, 2023, meets this requirement with a signed attestation confirming the vaccination date included with your records.
  Participants are also responsible for maintaining compliance with any future COVID-19 booster or vaccination requirements established by UCSF.
  1. Flu Shot: *Requirement: Annual Flu Shot
  2. Hepatitis B: *Requirement:
  Tuberculosis (TB) Requirements: *Requirement: Proof of 2 Negative TB skin test (volunteers must complete option A, B, or C): q
  
  Option A: Two negative TB skin tests: 1 within the last three months and 1 within the last year
  Option B: 1 Negative QuantiFeron Blood Test and 1 Negative TB skin test within the last three months
  Option C: 1 Negative chest x-ray report completed within the past year, if you have a positive TB skin test (must provide proof of positive skin test results)
  
  For the TB just select one option. No mixing options.
  
  Submit all required proof to David Poon (David.Poon@ucsf.edu). Please have the list completed prior to submission.
- Question: Tell us how you feel about conducting and performing your 40 hours at UCSF? Why UCSF?
- Have you previously gone through another radiology department's observation program?*
  
  YesNo
- Please be advised that during your observation, the technologist you will be following maybe assessing if you are a good candidate to be in the imaging field. As an observer, what can you do to ensure and show during the observation to put that technologist at ease and validate you are a strong student.
- Which radiography program do you intend on applying for? If you are applying for other programs outside diagnostic radiology. Please indicate by "free typing."
  
  City College of San FranciscoOakland Merritt's ProgramMills Peninsula Radiography ProgramFoothill's ProgramKaiser School of Allied HealthOther
- 1. During your observation, you will be following an radiologic technologist. While we encourage you to ask questions during your time here. Please refrain from asking questions if you notice that the radiographer is directly dealing/speaking to the patient. Select an appropriate time to ask your question. The priority is always the patient.
  
  2. During you observation, you will be assigned to places that will require you to be directly chaperoned by a technologist. The Emergency Department and the Operating Room are areas that require the observer be directly supervised at all times.
  
  3. You must follow the directions of the technologist at all times.
  
  4. Participants may not assist the technologist in any way. This includes the following:
  
  Ø No patient assisting, touching the patient, and "try to be helpful"
  
  Ø No touching the X-ray equipment and or the supplies or devices
  
  Ø No driving an imaging equipment
  
  5. No “horsing around” in front of a patient, staff, or visitors
  
  6. Participants are responsible recording keeping of their observation hours.
  
  7. Do not ask for a letter of recommendation from a technologist, staff, or patient
  
  A letter of recommendation is a letter written on behalf of an applicant by someone who can vouch for that person's educational or professional performance.
  
  It is impossible for us to ascertain the qualities you have during your time here. Please refrain from asking anyone for a letter of recommendation. Most programs have changed their policies and for some no longer accepts it. City College does not accept letters of recommendation as part of their application process.
  
  This is not an exhaustive list.
- The following video addresses HIPPA Compliance. Please do review this video.
- Youtube
- What is HIPPA and why is it so important to safe guard HIPPA? Explain.*
  To ensure you understand the importance of HIPPA.
- Please download, review and sign the form. After you are done, include these forms as part of the imunization reocrds forms you will email me.
- Waiver of Liability- By agreeing and signing this form, you will not hold UCSF and its employees responsible for any injury or damage during your observation time at UCSF.
- Patient Privacy Form: By signing this form, you agree that you will not disclose, take any information about the patient, take pictures, or disclose whether written or oral to anyone outside UCSF Medical Center. In addition, you agree you will abide by the contents of the form.
- The form below, "Volunteer Hour Verification form" is the form to document your attendance with the CCSF Program. If you are intending on applying for the CCSF DMI Program, please print this form and bring it with you each time you observe.
- Instructions for Vaccinations, and other paperwork. Please email proof of vaccinations, release forms, and UCSF HIPPA Forms to David.Poon@ucsf.edu. DO NOT EMAIL the forms in pieces. Email all the forms in one email (more than one attachments if fine). THank you
- Why did you choose imaging?*
- Emergency Contact*
  
  First NameLast Name
- Emergency contact Phone Number*
  
  Area CodePhone Number
- Emergency Contact Email*
  example@example.com
- Date
- Your Signature*
  
  I have read and agree the information above.
- Should be Empty: