Rev.
11/15/10 YALE-NEW HAVEN HOSPITAL
APPLICATION FOR RESIDENT OBSERVERS
Observer’s Name:
_____________________________________________________________________________________________
(Last Name) (First Name) (Middle Name)
Department :__________________________________________________________________________________________________
Section: ___________________________________________ From: ____________________ To: _______________________
Purpose of Observation Visit:
______________________________________________________________________________________________
Medical School: ______________________________________________________________ Degree:_______________
Graduation Date: __________________ Foreign Medical Graduate ¨ Yes ¨ No ECFMG Issue Date: ___________
MM/DD/YYYY MM/DD/YYYY
Internship, residency, fellowship training: Appointment Dates
(Note clinical or research) U.S. and Canadian appointments PGY Hospital
Only Name of Training program (i.e. medicine, pediatrics, Level
surgery, etc.) From: To:
Attestation
The individual listed above is requesting to visit Yale-New Haven Hospital (YNHH) strictly as an observer for the period of time indicated. I agree
that I will be responsible for this individual and he/she will be accompanied at all times by a member of the House Staff/Medical Staff while he/she
is on YNHH premises.
We agree and understand that, if approved as an observer, the applicant is permitted to observe patient care only and that he/she will have no
patient contact. To this end, he/she will be prohibited from engaging in any of the following: speaking with or examining patients, providing
opinions or consultation about any patient hospitalized at YNHH or reading or writing in patient medical records. If approved as an observer in
the operating rooms or other procedural areas, the applicant understands that he/she must remain unscrubbed at all times and is not permitted to
operate any equipment connected with the delivery of patient care.
The applicant:
• agrees to display appropriate identification while on YNHH premises
• agrees to complete the attached immunization testing record and fulfill documentation requirements as stipulated in the
attached letter
• attests to having read the YNHH Policies and Procedures regarding Infection Control, Standard Precautions and Safety and
Security
• agrees to sign and return “Medical Staff Guest and Observer Confidentiality Agreement”
Resident’s Signature: ____________________________________________ Date: __________________________________
YNHH Chief of Service Signature __________________________________ Date: __________________________________
YNHH Department Contact Person: ___________________________________ Contact Email: ________________________________
Name of Current Department (not YNHH) _______________________________ Hospital: ______________________________________
Dept. Telephone # _________________________________ Dept. Fax # _____________________________________________________
