MS - Clinical Observership Experience Application

Clinical Observership Experience Application
Your Name*

First NameLast Name
Email
example@example.com
Student Type*
If "Other" please specify
Do you already have a provider to shadow?*

yesno
If yes, who?*
Dr. First Name, Last Name
If no, please let us know what subspecialties you are interested in shadowing in*
Please know, Pediatric Emergency Medicine and Surgery do not permit any shadowers
Have you and the provider discussed what dates you would be completing your shadowing experience?*

yesno
If yes, when?*
PCH requires that a date be finalized to be approved. Please schedule shadowing start date at least 6 weeks out from when you submit this application.

Background Check and Drug Screen
Please make sure you have cleared a University of Utah Background Check and Drug Screen. If you're either a University or Intermountain employee, please email to let us know at ped.education@hsc.utah.edu

The cost for both amounts to $100 total.

You can purchase either/both here: Background Check and Drug Screen
I have purchased the Background Check and/or Drug Screen*

yesno
Application Document Uploads
UPLOAD ALL DOCUMENTS TO:

https://uofu.app.box.com/f/57ad310365f443c9a6a5478b991d353b
U of U Student Observer Application
U of U Student Observer Application*

COE Application
Cancelof
HIPAA Certificate
HIPAA Certificate*

Cancelof
PCH Student Observer Request
Did you complete the PCH Student Observer Request via the link: https://intermountainhealth.formstack.com/forms/observation_request*

Yes
PCH Medical Student Application*

Cancelof
Documentation stating that shadowing experience is required to pass Institutional Course*

Cancelof
Should be Empty:

Clinical Observership Experience Application