2022 Observer Application

Logan Health seeks to contribute to the education of individuals by maintaining an observer/shadowing program committed to providing quality, career exploration experiences.
You must be at least 16 years of age to observe in our facilities. If you are under the age of 18 you will need to have your legal parent or guardian fill out the Minor Observer Agreement and provide it with the Observer application.
Once a completed interest form is submitted; please allow 48 Business Hours to receive a response that the Student Affiliations office is processing your paperwork.

**Observer applications submitted with incomplete requirements will be rejected and the applicant notified via email.

1. Today's Date *

2. First and Last Name *

3. Email *

4. Date of Birth *

5. If you are under the age of 18, you are required to upload a signed Observer Minor Agreement Form.

6. Phone Number (included area code) *

7. In Case of Emergency - Please Provide Emergency Contact Name *

8. In Case of Emergency - Please Provide Emergency Contact Phone Number *

9. Are you a Logan Health Employee? *
Yes   No  

10. If you are a Logan Health Employee, which department do you work in?

11. Which Logan Health facility are you interested in observing? *
Logan Health Kalispell   Logan Health Whitefish   Logan Health Conrad   Logan Health Cut Bank   Logan Health Shelby   Logan Health Polson   Logan Health Other  

12. If other, please specify.

13. List a minimum of three specific departments you are interested in observing, in order of preference. Understand that some areas may not be available during your observation period. *

14. What professional role are you interested in observing? *
Registered Nurse    Physician    Physician Assistant    Nurse Practitioner    Other patient care role    Other non-patient care role   

15. If you chose other patient care role, or other non-patient care role, which specific role do you want to observe?

16. Is there a specific person(s) you wish to observe? Please list their name(s) here.

17. Have you spoken to them about observing?

18. What specific goal(s) are you wanting to accomplish by observing at Logan Health? *

19. List exact dates you are available to Observe. Be sure to list several options to allow for scheduling keeping in mind that your first date of availability should be no sooner than 2 weeks from the date of this application. *

20. Upload Immunization Requirement: MMR (measles, mumps, rubella): Two official records of vaccinations OR positive results from titers showing immunity. *

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

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

23. Will you be observing on the Logan Health Campus for less than 8 hours? *
Yes - I will be observing less than 8 hours and I will complete the online TB Management form.   No - I plan to observe greater than 8 hours and will follow the TB testing requirements.  

24. Upload Immunization Requirement: TB - If you will be observing on the Logan Health campus for GREATER than 8 hours, you are required to upload one of the following: QuantiFERON/TSpot with negative result OR Two Negative skin PPD's within the last 12 months.

25. Upload Immunization Requirement: COVID Vaccine or Logan Health approved COVID vaccine exemption(upload if you will be on Logan Health campus more than 8 hours).

26. Upload a current and professional photo here for your Observer ID badge. No hats or sunglasses can be worn in the photo. *

27. By typing my full name I agree that I will abide by Logan Health Dress Code Policy HR530 to ensure that I project a positive, professional image in conjunction with specific jobs while maintaining the safety of our patients. *

28. By typing my full name I agree that I will comply with the Compliance Program guidelines contained in Logan Health Organization Code of Conduct policy A302. *

29. By typing my full name I agree that I will abide by Logan Health Hand Hygiene Policy IC435 that defines the standards required for hand hygiene practices, within Logan Health facilities, that must be adhered to by all to prevent the spread of infection. *

30. By typing my full name I agree that I will abide by the Student/Non-Employee Training Programs policy EDU800. *

31. By typing my full name I agree that I will abide by the Logan Health Observer Program, EDU805 policy. *

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

33. I attest I will wear a surgical mask and eye protection while at Logan Health as defined by the protocols for my scheduled observation area. *

34. I attest that I will stay home if sick. *

35 A. Medical Release Consent - This Medical Release must be signed by each observer over the age of 18. Observers over the age of 18 must type their 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 Logan Health. Further I hereby waive any liability on the part of Logan Health, its directors, agents and employees, arising out of such medical treatment. I also agree to any charges that may be incurred for such treatments.

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.

35 B. Medical Release Signature: Please enter legal name *

36. 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 of the above. *

37. Thank you for your application. How did you hear about the observer program? *
Social Media   Internet Search   Career Fair   School Counselor   HOSA   Another Logan Health Employee   Other