Application to Observe a Physical Medicine and Rehabilitation Professional

Thank you for your interest in observing our department. Your request and application will be submitted to the Physical Medicine and Rehabilitation Department. This website will be checked the 1st and 15th of each month. We cannot guarantee that all requests will be met due to high level of interest and staffing.

Applicants will not be considered without a completed observer packet. You will receive email stating whether your hours have been approved.

The following are requirements to being an observer:
1. Minimum of 16 years of age (if under 18 years of age, must have a parental consent signed – see below)
2. Signed Medical Clearance Form to include:
  - Medical Physical Examination (completed within the last 12 months)
  - Proof of MMR and/or Varicella shots
  - Proof of TB Test and results
3. Signed Confidentiality Form
First Name*
Last Name*
I am 16 years of age or older:*
- Yes
- No
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone Number*
Email Address*
School*
Which discipline are you interested in observing?*
- Occupational Therapy
- Physical Therapy
- Speech Therapy
Special Interests for Observing (examples include but are not limited to: speech therapy swallow study, occupational therapy acute care, physical therapy outpatient, physical therapy acute care pediatrics; please consult website for all areas)*
Desired Hours and Dates to Observe (max is 40 hours)*
The following hours for observation are available (not including 12- 1 p.m.):
Acute Care observation: Mon-Fri 8 a.m. - 4 p.m.
Outpatient observation: Mon-Fri 8 a.m. - 5 p.m.
Speech observation: Mon-Fri 9 a.m. - 4 p.m.

Desired Hours to Observe:
First Choice*
Second Choice*
Goals of Observation Personally/Professionally*
Emergency Contact*
Emergency Contact Relationship*
Emergency Phone*
Please upload the following completed forms in one file:
1. Health Clearance Form (completed within the - last 12 months)
2. Signed Confidentiality Form
3. Parental Consent Form (if needed)
Once all forms are completed and have been reviewed, you will receive an email with the specific dates/times and therapist you will be observing.
Attachment*

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Application to Observe a Physical Medicine and Rehabilitation Professional

Desired Hours to Observe:

Please upload the following completed forms in one file:

Required Form