<p> 6/2014 ProHealth Care Request for Observation</p><p>All information requested on this form must be complete, and submitted to the Center for Learning & Innovation before an observation experience may be scheduled. Fulfillment of this request is contingent upon approval from the department manager. We reserve the right to deny requests. (Please allow at least three weeks to process your request.) </p><p>Observer Name (Please Print): ______Email: ______</p><p>Address: ______City: ______Zip: ______</p><p>Phone: ______School/ Organization: ______Age (if under age 18): ______</p><p>Purpose for Observation Request: ______</p><p>Possible Observation Date(s): ______# of hours requested: ______</p><p>Department & Role to be Observed: ______Facility preferred: Waukesha Memorial Hospital ______Oconomowoc Memorial Hospital ______Other ProHealth Care site (please state): ______ProHealth Care Employee Sponsor or Physician (if known): ______Phone: ______</p><p>Immunization Record: Requests will NOT be considered without copies of complete immunization data. Date Live MMR ______OR Date Rubella titre indicating immunity ______Date Varicella ______OR Date of Chickenpox or positive Varicella titre indicating immunity ______Date TB Skin Test ______Results ______(Must be within the last 12 months) Date Seasonal Flu Vaccine ______</p><p>Life Safety Requirements: (Please note – requests will not be considered without completing this requirement) I have read and understand the information provided to me on the Life Safety Code Sheet (Separate form).</p><p>Observer signature: ______Date: ______</p><p>Confidentiality Agreement: I understand that my request to observe at a ProHealth Care site may include access to information regarding patients and their care, which I must protect and keep confidential. </p><p>Protected information can be obtained through observation; conversation with a patient, family member, physician, or other caregiver; and/or from the patient’s written or electronic medical records. Information that is protected includes, but is not limited to:  Patient is or has been receiving care in one of our facilities.  The patient’s history and diagnosis.  The care the patient does or does not receive.  The patient’s ability to pay.  The patient’s response to treatment.  Information about the patient’s family.</p><p>I agree to safeguard, and will not share any of the above information. By signing the attached agreement, I agree to knowingly and voluntarily maintain the utmost confidentiality as it relates to any patient information. (Please note – you must also read and sign the enclosed Confidentiality Agreement)</p><p>Observer signature: ______Date: ______</p><p>Parental/Guardian Consent (if observer under 18 years of age): Name: ______Relationship: ______</p><p>Please return this form to: Stephanie Warren, PHC: Center For Learning & Innovation 725 American Avenue Waukesha, Wisconsin 53188 Questions: please call 262-928-2139 Fax number : 262-928-2092</p><p>Date of observation ______Department /Role Observed ______</p>