ALLEGHENY GENERAL HOSPITAL—WESTERN PENNSYLVANIA HOSPITAL
MEDICAL EDUCATION CONSORTIUM
RESIDENT OBSERVERSHIP APPLICATION
APPLICANT INFORMATION
Last Name ________________________________ First Name ___________________ M.I. _________
Street Address ___________________________________________________________ Apt. # _______
City ______________________________________ State ___________________ Zip ________________
Gender ____ M _____ F Phone Number ___________________ Date of Birth _____________
Emergency Contact _______________________________ Relationship _______________________
Emergency Contact Phone _______________________________________________________________
RESIDENCY PROGRAM INFORMATION
Current Residency Training Program: _________________________________ Program Level _____
Sponsoring Institution Name: ____________________________________________________________
Street Address ________________________________________________________ ________________
City ______________________________________ State ___________________ Zip ________________
Program Director ____________________________ Residency Coordinator _____________________
OBSERVERSHIP INFORMATION
Department where you will be observing _________________________________________________
Site Sponsor’s Name _____________________________ Dates of Observership _________________
REASON FOR OBSERVATION REQUEST (Please explain why you are interested in this observation
opportunity)
Allegheny General Hospital Sponsor
Last Name _______________________________ First _________________ M.I. ________
Disclaimer and signature
By signing this application,
I request consideration for a period of observation at Allegheny General Hospital.
I understand that I will not be permitted to engage in patient care.
At any time, I will not be asked or allowed to answer specific questions about a patient’s care or
treatment, or otherwise provide medical or professional opinions.
I understand that through my sponsor I will be expected to follow all of Allegheny General
Hospital’s policies, rules and regulations, specifically those regarding infection control, safety
and confidentiality.
I agree to follow the directives of my sponsor. I understand that I must remain with my sponsor
at all times.
I understand that I am on Allegheny General Hospital property at my own risk and insurance
coverage, that I will not be indemnified/insured by Allegheny General.
I understand that if I breach any policies or obligations, my permission to act as an observer will
be withdrawn and I may be asked to leave immediately.
I certify that my answers are true and complete to the best of my knowledge. If this application
is approved, I understand that I am responsible for submitting all required documents.
I am enclosing a copy of my current proof of PPD testing and a letter of good standing
from my program director.
Applicant Signature __________________________________________ Date ___________________
As program director, I approve of the above-named resident’s request to participate in an observership
at Allegheny General Hospital.
Program Director’s Signature __________________________________ Date _____________________
West Penn Hospital Sponsor
Last Name _______________________________ First _________________ M.I. ________
Disclaimer and signature
By signing this application,
I request consideration for a period of observation at West Penn Hospital.
I understand that I will not be permitted to engage in patient care.
At any time, I will not be asked or allowed to answer specific questions about a patient’s care or
treatment, or otherwise provide medical or professional opinions.
I understand that through my sponsor I will be expected to follow all of West Penn Hospital’s
policies, rules and regulations, specifically those regarding infection control, safety and
confidentiality.
I agree to follow the directives of my sponsor. I understand that I must remain with my sponsor
at all times.
I understand that I am on West Penn Hospital property at my own risk and insurance coverage,
that I will not be indemnified/insured by West Penn.
I understand that if I breach any policies or obligations, my permission to act as an observer will
be withdrawn and I may be asked to leave immediately.
I certify that my answers are true and complete to the best of my knowledge. If this application
is approved, I understand that I am responsible for submitting all required documents.
I am enclosing a copy of my current proof of PPD testing and a letter of good standing
from my program director.
Applicant Signature __________________________________________ Date ___________________
As program director, I approve of the above-named resident’s request to participate in an observership
at West Penn Hospital.
Program Director’s Signature __________________________________ Date _____________________
APPLICATION FOR RESIDENT OBSERVER AT ALLEGHENY GENERAL HOSPITAL
SPONSOR’S AUTHORIZATION AND ENDORSEMENT
Service/Department _____________________________________________________________
Start Date ___________ End Date ___________
OBSERVERSHIP SHOULD NOT EXCEED 2 CONSECUTIVE WEEKS
Sponsor Statement:
As an Allegheny General Hospital employee/or member of the Medical Staff with appropriate privileges
for procedures, I endorse the applicant to complete the approved observership at Allegheny General.
This applicant will be under my FULL supervision. I have reviewed the application and credentials
submitted by this applicant to be a Resident Observer at Allegheny General. By my signature below, I
agree to the following:
I support the application and agree to personally oversee and supervise this individual during
the approved period of observation.
I will ensure the Resident Observer will abide by Allegheny General Hospital’s policies, rules,
regulations, and will review the hospital’s rules for Patient Confidentiality, Safety Education and
Standard Precautions.
I understand that the Resident Observer is permitted only to view patient care, and only with
patient consent. I agree that the Resident Observer will have no direct patient contact or
provide any type of medical care.
I will ensure the Resident Observer will wear his/her identification badge at all times while in the
Hospital.
I will ensure the Resident Observer will follow required hand washing practices while at the
Hospital, specifically after using the bathroom, and upon entering or leaving a patient care area.
The Resident Observer will not enter isolation rooms, and will not come to observe when he/she
is sick, has a fever, or has been exposed to a contagious disease.
Last Name ________________________________________ First _____________________ M.I.______
Specialty _________________________________________Office Phone _________________________
Sponsor Signature _____________________________________________________________________
APPLICATION FOR RESIDENT OBSERVER AT WEST PENN HOSPITAL
SPONSOR’S AUTHORIZATION AND ENDORSEMENT
Service/Department _____________________________________________________________
Start Date ___________ End Date ___________
OBSERVERSHIP SHOULD NOT EXCEED 2 CONSECUTIVE WEEKS
Sponsor Statement:
As a West Penn Hospital employee/or member of the Medical Staff with appropriate privileges for
procedures, I endorse the applicant to complete the approved observership at West Penn. This
applicant will be under my FULL supervision. I have reviewed the application and credentials submitted
by this applicant to be a Resident Observer at West Penn. By my signature below, I agree to the
following:
I support the application and agree to personally oversee and supervise this individual during
the approved period of observation.
I will ensure the Resident Observer will abide by West Penn Hospital’s policies, rules,
regulations, and will review the hospital’s rules for Patient Confidentiality, Safety Education and
Standard Precautions.
I understand that the Resident Observer is permitted only to view patient care, and only with
patient consent. I agree that the Resident Observer will have no direct patient contact or
provide any type of medical care.
I will ensure the Resident Observer will wear his/her identification badge at all times while in the
Hospital.
I will ensure the Resident Observer will follow required hand washing practices while at the
Hospital, specifically after using the bathroom, and upon entering or leaving a patient care area.
The Resident Observer will not enter isolation rooms, and will not come to observe when he/she
is sick, has a fever, or has been exposed to a contagious disease.
Last Name ________________________________________ First _____________________ M.I.______
Specialty _________________________________________Office Phone _________________________
Sponsor Signature _____________________________________________________________________
