Doar & Affiliates Student Observation Request Form Page 2
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Student Observation Request Form
Exhibit A
Observation Only
Responsibility And Confidentiality Statement
For and in consideration of the benefit provided the undersigned in the form of experience in evaluation and
treatment of patients of __________________________________________________________________
("Facility"), the undersigned and his/her heirs, successors and/or assigns do hereby covenant and agree to assume all
risks of, and be solely responsible for, any injury or loss sustained by the undersigned while participating in the
observation at Facility unless such injury of loss arises solely out of Facility's gross negligence or willful
misconduct.
My sponsoring facility, academic facility, employer or I have personally provided evidence of my professional
and/or general liability insurance to the Facility department authorizing my observation activity. If I do not provide
evidence of insurance, I am personally liable for all injury, illnesses, or damages to myself or others related to my
participation in this event. I hereby release, hold harmless, acquit, and forever discharge the Facility, Center for
Pediatric Therapies, Inc., All Care Home Health, Inc., Accelerated Care, Inc., Martinsville Physical Therapy &
Industrial Rehabilitation, Inc., Danville Orthopedic & Athletic Rehabilitation, Inc., and each of these entities, their
agents, servants, successors, or assigns, for any and all actions, causes of action, claims, demands, damages, costs,
expenses, any present or future healthcare charges related or unrelated to medical treatment and compensation,
arising out of, or related in any way to my observation in patient care areas in this Facility or its associated entities.
In addition, the undersigned agrees to:
1. Abide by the Policies and Procedures of the Facility;
2. Comply will all applicable federal, state and local statutes and regulations in connection with the observation;
3. Obtain prior written approval from the Facility before publishing any materials relating to the observation.
The undersigned hereby acknowledges her/her responsibility under applicable Federal law to keep confidential any
information regarding Facility patients, as well as all confidential information of Facility. The undersigned agrees,
under penalty of law, not to reveal to any person or persons except authorized clinical staff and associated personnel
any specific information regarding any patient and further agrees not to reveal to any third party any confidential
information of Facility, except as required by law or as authorized
by Facility.
____________________________________________________________________________________________
Observation Participant Name
Date
____________________________________________________________________________________________
Observation Participant Signature
Date
____________________________________________________________________________________________
Parent or Guardian Name if Participant is a Minor
Date
____________________________________________________________________________________________
Parent or Guardian Signature if Participant is a Minor
Date
____________________________________________________________________________________________
Witness Name
Date
____________________________________________________________________________________________
Witness Signature
Date
____________________________________________________________________________________________
Location Manager Signature
Date
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