Clinical Observership Program

PROGRAM APPLICATION
(Please print)

Clinical Department to which application is being submitted: Clinical Nutrition

I. PERSONAL AND DEMOGRAPHIC INFORMATION

Name: _______________________________________________________________________
Last First Middle
Date of Birth: ________/_______/________________
month day year

Current Home Address:

_______________________________________________________________________________
_______________________________________________________________________________
City: __________________ State: _____________ Zip Code: _____________________________
Country ________________________________________________________________________
Home Phone Number: _____________________ Mobile Number: _________________________
Email Address: ___________________________ Fax: __________________________________

II. CURRENT POSITION:

Hospital/Facility: _______________________________________________________
Address: _______________________________________________________________
City: ________________________________State/Country: ______________________
Phone Number: ____________________________Fax Number: ___________________
Rank/Title: ________________________________Department_____________________
If less than three years in your current position:
Former Hospital/Facility: ________________________________________________
Address: _______________________________________________________________
City: ________________________________State/Country: ______________________
Phone Number: ____________________________Fax Number: ___________________
Rank/Title: ________________________________Department_____________________

III. EDUCATIONAL INFORMATION

Name of Professional School:
________________________________________________________________________

Address: ________________________________________________________________

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City: ______________________ State/Country: ________________________________

Phone Number: (______) __________________ FAX Number: (______) ____________

Attended from: _______ / _______ / _______ to: _______ / _______ / _______

IV. Proficiency of the English language is required for observers at NewYork-

Presbyterian Hospital (NYPH). NYPH does not require language testing for
Observers.
Do you speak English?
Fluent _______ Good ______ Average _______ Poor __________
Do you read/write English?
Fluent _______ Good ______ Average _______ Poor __________

VIII. PROFESSIONAL REFERENCE

Submit a reference letter from one individual who has knowledge of your current clinical
abilities, work ethics, health status and can / will provide specific written comments on
these matters upon request from NewYork-Presbyterian Hospital. The named individual
must have acquired the requisite knowledge through recent observation of your
professional practice over a reasonable period of time, and must have had organizational
or supervisory responsibility for your professional performance. This individual should
not be related to you by family or current or impending professional partnership.
Reference Letter
Name of Person Completing Letter: ______________________________
Title: ______________________________________________________

IX.HEALTH STATUS:
Do you currently have any mental or physical condition that would:
1. Compromise your ability to perform any essential functions of your responsibilities?
� Yes � No

2. Adversely affect your ability to perform the essential functions required by the clinical
observership you are requesting? � Yes � No

3. Are you habituated or addicted to depressants, stimulants, narcotics, alcohol or drugs

or any substances which may alter your behavior? � Yes � No

If the answer to any of the foregoing questions is YES, please provide a full
explanation on a separate sheet and attach.
X. CLINICAL OBSERVER GUIDELINES
1. A clinical observer is not allowed to have any patient care responsibilities or
engage in any “hands-on” experience with patients and their families.
2. Clinical observers must be clearly identified to all patients and staff, and
permission must be obtained from each patient (or proxy) for observer to be

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 present during any encounter. Should a patient request a clinical observer to
leave at any point during an encounter, the observer must leave at once.
3. Clinical observers are responsible for their own personal transportation,
accommodations, meals, medical insurance, required immunizations and any
other personal expenses incurred while at NYPH.
4. Clinical observers are not considered employees of NYPH or members of the
staff. Therefore, they will not act as members of the staff or employees.
5. Clinical observers do not receive any salary, other remuneration or compensatory
reimbursements or benefits from NYPH.
6. On the first day of the observership, the clinical observer is required to go to the
clinical department of the observership, obtain an “ID badge authorization letter.”
The clinical observer will then present the letter to the security department and
obtain the NYPH temporary ID badge. On the last day of the observership and
prior to departure from NYPH, the clinical observer will return the temporary ID
badge to the security department.
7. Clinical observers must wear the temporary NYPH ID badge at all times while
on hospital premises.
8. Clinical observers may only be on hospital premises during those hours in which
the observership takes place.
9. Clinical observers must always be accompanied by their sponsor or a hospital
employee while on hospital premises.
10. A clinical observer may attend educational conferences, seminars and committee
meetings related to their observership.
11. Clinical observers are expected to adhere to all NYPH standards, rules and
regulations, as well as all applicable laws while at NYPH.
12. A clinical observership may be terminated (or its duration may be changed) by
the observer or the NYPH sponsor at any time.
13. Clinical observers may be charged a fee for their observership, including an
application fee.

XI. CONFIDENTIALITY AGREEMENT

As a clinical observer at NewYork-Presbyterian Hospital (Hospital), I understand that I
may have access to confidential information which may include, but is not limited to,
information relating to: patients (such as records, conversations, admission information,
patient financial information),including specially protected HIV related information,
employees, affiliates, other practitioners (such as strategic plans, internal reports, memos,
peer review information, communications, proprietary computer programs, source code,
proprietary technology),and third party information (such as computer programs, client
and vendor proprietary information, source code, proprietary technology). Accordingly,
as a condition of, and in consideration of my access to confidential information and my
participation in the clinical observership program, I promise that: I will use confidential
information only as needed by me to perform my legitimate duties as a clinical observer.
This means, among other things, that: I will not access confidential information that I
have no legitimate need to know; I will not in any way divulge, copy release, sell, loan,
revise, alter, or destroy any confidential information, except as properly authorized within
the scope of my professional activities as a clinical observer affiliated with NewYork-

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Presbyterian Hospital; I will not misuse confidential information or, by failing to
safeguard confidential information, allow unauthorized persons to obtain or access
confidential information; I will safeguard and will not disclose any authorization given to
me that allows me to access information; I accept responsibility for all activities
undertaken using my authorization information; I will report to the Clinical Nutrition
Office as applicable, any suspicion or knowledge that my authorization or any
confidential information has been misused or disclosed without the Hospital’s
authorization; understand that my obligations under this Agreement will remain in effect
at all times during my participation as a clinical observer and continue after my
termination or expiration of my participation; I understand that I have no right or
ownership interest in any confidential information referred to in this Agreement.
NewYork-Presbyterian Hospital may at any time revoke my authorization, or access to
confidential information; and I understand that my failure to comply with the terms of
this Agreement will result in the imposition of sanctions in accordance with Hospital
policy, State and federal law, and may include suspension and termination of my
participation in the clinical observership program. I will sign a confidentiality agreement
before the start of the observership.
XIII. AFFIRMATION
I represent that information provided in or attached to this application is accurate. I
understand that a condition of this application is that any misrepresentation,
misstatement, or omission from this application may be cause for automatic and
immediate rejection of this application and may result in the denial of participation in the
clinical observership program. Upon subsequent discovery of such misrepresentation,
misstatement, or omission, the Hospital may terminate my participation in the clinical
observership program. I understand and agree to abide by the guidelines outlined above.
Applicant's Name:
____________________________________________

________________________________
Applicant's Signature and Date

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