Doar & Affiliates Student Observation Request Form

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DOAR & Affiliates
Student Observation Request Form
Instructions to Student:
1) Determine Location/Facility you would like to observe. See
2) Complete this form.
3) Sign and attach Exhibit A to this request.
4) Complete HIPAA training. Attach documentation of training completion to this request.
5) Sign and attach Exhibit B to this request.
6) Submit request with attachments to the Location Manager for review/approval.
Student Name:
DOB:
Home Phone:
Cell Phone:
Email Address:
Street Address:
City:
State:
Zip:
School:
Level of Student:
Expected Graduation Date:
If Student is a Minor, Parent or Legal Guardian Name:
Home Phone:
Cell Phone:
Emergency Contact Name:
Relationship to Student:
Home Phone:
Cell Phone:
Location/Facility Requested:
Specific Hours/Days Requested:
Start Date Requested:
End Date Requested:
Note: Observations are designed to be short-term (less than 2 weeks) and do not include hands-on experience.
Purpose of Observation:
REQUEST APPROVAL – TO BE COMPLETED BY LOCATION MANAGER
Location/Facility:
Student Preceptor:
Specific Hours/Days:
Start Date:
End Date:
Location Manager Signature:
Date:

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