Observer Application

Please fill out this form completely. When uploading documents or photos please do not use documents with HEIC extensions. We cannot open them.
We appreciate your interest in observing at Kalispell Regional Healthcare. Please give us at least 30 days to process your request. We will try our best but may not be able to honor your request. Approvals are based on the number of requests received, census, staffing, and space restrictions. Observer requests are processed once all requirements listed below are met. If your observation has not been completed within 6 months from the date of your application submission, you will need to start the process over.
 

Are you under 18 years old? *
Yes   No  

Upload the signed Observer Minor Agreement. This is required if you under the age of 18.


Are you a KRHS employee? *
Yes   No  

If yes, in which KRHS department do you work?

First and Last Name *

Today's Date *

email *

Phone Number (include area code) *

Date of Birth *

Name of Primary Physician *

In Case of Emergency Contact *

Emergency Contact Phone Number *

Why are you interested in observing at KRH? *

Position you are interested in Observing. Please pick one and be specific or the request cannot be processed. *

Is there a specific person you wish to observe? If so, who? Have you spoken to this person? *

Have you been approved or have you had any communication with the manager or supervisor of the department in which you would like to observe? *
Yes   No  

If so, who? If you have not, please enter N/A. *

Dates you are available to Observe. Please be specific but allow enough time and options for the approval process and scheduling purposes. *

How did you hear about KRH observer program?

I reviewed and understand the Instructions, Requirements and Policies. I agree to comply knowing that any incidences of misconduct or infractions may be subject to termination of the learning experience and/or personal liability. *
Yes   No  

You will need to provide your immunization records below to submit your application.


MMR (measles, mumps, rubella): Two official records of vaccinations OR positive results from titers showing immunity required *


Tuberculosis (TB): Please download the TB Questionnaire Fill it out and upload it below for approval. If you have a current negative TB test within the last 11 months you can upload it here in lieu of the TB Questionnaire. You can find the TB Questionnaire at the KRH Observer Website. *


Varicella (chickenpox): Record of two vaccinations OR positive titer results showing immunity OR record of having the disease verified by your healthcare provider. *


Tdap (tetanus w/pertussis): Vaccination record is required. This is the Tdap not the Td or DPT vaccination *


Influenza vaccination:


Upload a current, conservative, professional photo here for your student ID badge. Please make sure the photo follows the HR530d Dress Code Policy. No hats or sunglasses can be worn in the photo. You can find the Dress Code Policy on our website at the KRH Observer Website. *


Confidentiality. Observers must comply with confidentiality. In the course of learning experiences, observer may be exposed to private and confidential information about KRH patients and employees. Observers must understand that this information may NOT be shared outside of the Observation Experience with any member of the public. The intentional breach of confidentiality regarding patients and/or organization employees is considered gross misconduct and reason for termination of the Observation Experience and may subject observers to personal liability up to the maximum penalty under HIPAA laws. I have reviewed and understand the HIPAA Education and agree to maintain the confidentiality of Kalispell Regional Healthcare patients and employees, and their private information.


I Agree *
Yes   No  

This Medical Release must be signed by each observer over the age of 18. Observers over the age of 18 must type full name below and agree to the following statement: I hereby give my consent, in the event of injury or illness, for emergency medical/dental treatment, hospitalization or other treatment as may be necessary for my welfare by a physician, dentist, licensed nurse and/or other hospital employee during all periods of time in which I am participating in an Observation Experience at Kalispell Regional Healthcare (KRH). Further I hereby waive any liability on the part of KRH, its directors, agents and employees, arising out of such medical treatment. I also agree to any charges that may be incurred for such treatments.


Medical Release Signature: Enter Your Full Name *

I do hereby being of legal age, consent to the use of my name, picture, silhouette, caricature, video/film reproductions of my physical likeness, and/or verbal statements in print and/or audio reproduction in the marketing communications programs of Kalispell Regional Healthcare (KRH). This includes my personal story, but does not include any details of care received at KRH. Any materials that I have submitted are not under obligation to another party. I hereby release Kalispell Regional Healthcare from any liability resulting from said marketing communications programs. I have entered into this agreement to assist KRH with marketing, public relations, and charitable goals and hereby irrevocably waive any right to compensation for such uses.


This is my electronic signature, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.


Media Release Signature: Enter Your Full Name *

I attest I will maintain social distancing while eating in breakrooms or lunch areas. I will wear a mask in these areas when not eating or drinking. *
Yes  

I attest I will wear a mask and eye protection while at KRHS as defined by the protocols for my scheduled observation area. *
Yes  

I attest that I will stay at home if sick. I will email my Logan Health Student Coordinator and will call the contact for my observation, upon onset of any one of the symptoms below related to COVID-19. *
Yes  

At this time, do you have any new onset of symptoms such as chills, cough, sore throat, shortness of breath or difficulty breathing, loss of taste or smell, unexplained new onset of fatigue, body aches, headache, nausea or vomiting, diarrhea, congestion or runny nose? *
No  

At this time, do you have temperature >100? *
No  

I attest I will notify the individual or scheduling contact for my observation immediately and email my Logan Health Student Coordinator if I come in contact with a known or suspected case of COVID-19 at Logan Health or outside of Logan Health and I was not wearing proper personal protection. *
Yes  

Please enter any additional information here.

Signature: The information contained on this form is correct and complete to the best of my knowledge. Type your name in the box below to certify your agreement to all the above. *