UTMC Outside Learner/Observer Experience Registration

University of Tennessee Medical Center Outside Learner/Observer Experience Registration
Thank you for your interest in participating as an Outside Learner/Observer at the University of Tennessee Medical Center. This is an observation only activity. Observation experiences are not available to medical students or medical residents through the UTMC Outside Learner Observer Program. Participants must review the Guidelines for Outside Learner/Observer prior to completing the below documentation. By completing the following information, outside learner/observer attests to being 16 years of age or older requesting to participate at the University of Tennessee Medical Center in an educational experience or observership who is not enrolled in a health-related program through an "affiliated" educational institution.

Note: This form should be completed before beginning the observational or educational experience and with each change of clinical area/sponsor. If observation is extended or crosses calendar years, you will need to complete separate requests for each observation. Requests for the upcoming year will be accepted beginning December 15th.

If you have questions please contact:

Kelly Rozzell, UHS Compliance Specialist krozzell@utmck.edu

Donna Patty, UHS Compliance Manager dpatty@utmck.edu
I acknowledge that I have read, agree to and understand the information provided in the University of Tennessee Medical Center Guidelines for Outside Learner/Observer. This is an OBSERVATION ONLY activity with no direct patient care. Observation experiences are not available to medical students or medical residents through the UTMC Outside Learner Observer Program. While completing this experience, I will comply with these guidelines and requirements.*

I agree
Name:*

First NameMiddle NameLast Name
E-mail:*
Phone Number:*

Area CodePhone Number
Date of Birth*

MonthDayYear
Must be 16 years of age or older
Are you a UTMC Team Member?*

YesNo
Upload a recent photo*

Browse Files
Cellphone picture preferred, looking directly at camera. No filters or heavy shadows with plain background such as a wall or curtain. No head or face coverings except for religious purposes or prescription glasses. Picture should stop at the shoulders Cancelof
Emergency Contact Name:*

First NameLast Name
Emergency Contact Phone Number:*

Area CodePhone Number
I am (click all that apply): Note-Observation experiences are not available to medical students or medical residents through the UTMC Outside Learner Observer Program.*

865 Academy Student- If yes, STOP. Please contact Dr. Craig Pickett at cspickett@utmck.edu for more informationCollege/University StudentNursing StudentClinical LiaisonNon-Paid Research Assistant (If medical student, list school and year of study in Other option below)Working Professional (Define your occupation in the below Other option)Other
Reason for Outside Learner/Observational Experience Request (click all that apply):*

School RequirementsPre-entrance requirement for professional programBusiness reasonsExplore possible career choicesWorkshopTouringNon-Paid Research Assistant on approved Organizational QI/PI Project (list project number in Other option below)Non-Paid Research Assistant on IRB approved Research Project (list project number in Other option below)Other
What are your specific goals or objectives for your observational experience? What do you hope to learn?*
Will you be paid for this experience?*

YesNo
Name of sponsoring healthcare professional that approved this observation:*
His/Her UTMC Department:*
Sponsoring Healthcare Professional Email:*
Sponsoring Healthcare Provider Phone Number*

Area CodePhone Number
Limit requested observation date to actual approved observance dates approved by the sponsoring care provided. Requests with exended dates may be delayed and require additional approval or require submission of additional Outside Learner/Observer Experience Registration form. Research assistants and clinical liasions can request up to a maxium of six months.
Requested Start Date of Observation:*

MonthDayYear
Date
Requested End Date of Observation:*

MonthDayYear
Date
Vaccinations: We encourage you to be up-to-date with all recommended vaccines before you begin the observational experience. This helps to prevent spread of communiciable diseases. Documentation of the requested vaccines helps to ensure that observers understand our expectations to protect our patients, families and themselves. We reserve the right to request additional documentation regarding vaccination records as needed. Failure to provide documentation will result in delay or unapproved experience.

Sources for vaccine information include: pediatric vaccine records, health department, student services or TennIIS. To begin a TN immunization record request, please email TennIIS.Records@tn.gov

*Declination of vaccines will require an approval process.
Has the sponsoring healthcare provider approved the observation and the above dates?*

YesNO
Influenza Vaccine-Requested during Flu Season (October 1-March 31)

MonthDayYear
Date of Vaccine
Declination of Flu vaccine(s) due to:

Medical ContraindicationReligious BeliefsObservation date April 1st to September 30th
Declination of influenza vaccine will require approved outside learner/observer will be required to wear a surgical mask during observational experience for the duration of flu season (typically October 1st - March 31st).
At any time during your experience, will you be in contact with a healthcare professional, in a patient care area, clinical liaison, or clinical research role? If yes, additional vaccine information is requested. The below vaccines reduce the chance that you will acquire or spread vaccine-preventable diseases. Sources for vaccine information include: pediatric vaccine records, health department, student services or TennIIS. To begin a TN immunization record request, please email TennIIS.Records@tn.gov*

YesNo
Tdap Vaccination (normally received around 7th grade)

MonthDayYear
Date of Vaccine
Declination of Tdap vaccine(s) due to:

Medical ContraindicationReligious Beliefs
MMR Vaccine #1

MonthDayYear
Date of Vaccine
MMR Vaccine #2

MonthDayYear
Date of Vaccine
Declination of MMR vaccine(s) due to:

Medical ContraindicationReligious Beliefs
Documentation of two MMR vaccines required OR positive titers for measles, mumps and rubella.
Measles titer

MonthDayYear
Date of Titer
Measles Titer Result
Result of Titer
Mumps titer

MonthDayYear
Date of Titer
Mumps Titer Result
Result of Titer
Rubella titer

MonthDayYear
Date of Titer
Rubella Titer Result
Result of Titer
Hepatitis B vaccination history is required for any observer in patient care areas.
Hepatitis B Vaccine #1

MonthDayYear
Date of Vaccine
Hepatitis B Vaccine #2

MonthDayYear
Date of Vaccine
Hepatitis B Vaccine #3

MonthDayYear
Date of Vaccine
Declination of Hepatitis B vaccine(s) due to:

Medical ContraindicationReligious BeliefsNot observing in patient care areas
Documentation of three Hepatitis B vaccines required OR positive HbsAB titer.
HbsAB titer

MonthDayYear
Date of Titer
HbsAB Titer Result
Result of Titer
We cannot accept the history of the chicken pox as an indication of Varicella immunity.
Varicella Vaccine #1

MonthDayYear
Date of Vaccine
Varicella Vaccine #2

MonthDayYear
Date of Vaccine
Documentation of two Varicella vaccines required OR positive Varicella titer. We cannot accept the history of the Chickenpox as an indication of immunity.
Varicella titer

MonthDayYear
Date of Titer
Varicella Titer Result
Result of Titer
All submissions must be reviewed for completeness and the requested experience/dates must be confirmed with sponsoring healthcare provider. Please allow 30 days for review. An email request will be sent to the observer to address any incomplete information. Once all information is complete and confirmation of experience is approved, an email will be sent to observer/sponsoring healthcare provider regarding next steps.
Distribution of Form:

Please print 3 copies of the completed form before clicking submit button.
- Copy to be maintained in departmental file
- Copy to Human Resources if identification badge is required
- Copy to outside learner/observer
Should be Empty:

University of Tennessee Medical Center Outside Learner/Observer Experience Registration