STHS Observation Application Form

Name:*

Legal First NameLegal Last Name
Birth Date*

MonthDayYear
Phone Number:*

Area CodePhone Number
E-mail Address:*
If currently attending school, what school are you attending?
School Name
Is your request to fulfill a school requirement?

YesNo
If your request is to fulfill a school requirement, upload any documents related to the assignment for review.

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What healthcare department or role are you seeking to observe? Please respond in detail explaining your request. *
Your Detailed Response
Are you currently an employee of STHS?*

YesNo
If you have a family member or relative that works at STHS, please list their name(s) and role(s).
Your STHS Family Member(s) and/or Relative(s)
If you already have a point of contact at STHS that you would like to observe, please list their name(s) and role(s).
Your STHS Contact
How long of an observation experience are you seeking?*

A few hoursA few daysA few weeksA set amount of hours as required by schoolOther
Observation Health Requirements
In order to obtain clearance to observe at St. Tammany Health System, observers must demonstrate compliance with the below health requirements.
1. Documentation of a negative TB Skin Test within the past 12 months
2. Documentation of completed Measles, Mumps, & Rubella (MMR) series
3. Documentation of completed Varicella series or history of chickenpox
4. Documentation of received Tetanus Diphtheria Acellular Pertussis (Tdap) vaccine
5. Documentation of received Influenza vaccine
Upload documentation of all these requirements below.

There are no exceptions to these health requirements for observation; all submissions will be declined if the above health requirements are not successfully completed and attached to this request.
Upload documentation of a negative TB Skin Test within the past 12 months:*

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Upload documentation of completed Measles, Mumps, & Rubella (MMR) series:*

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Upload documentation of completed Varicella series or history of chickenpox:*

Upload a File

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Upload documentation of received Tetanus Diphtheria Acellular Pertussis (Tdap) vaccine:*

Upload a File

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Upload documentation of received Influenza vaccine:*

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