OBSERVER APPLICATION

University Hospital and Manhattan Campus for Albert Einstein College of Medicine

GENERAL PERSONAL INFORMATION

PLEASE TYPE OR PRINT CLEARLY

Middle Name
Please circle all that
Social Security No.
applies: DO, MD, MBBS,
DDS, DMD, Other__________
I Am ROTATING To The Following Graduate Program: Program Description:
Is This Program ACGME Accredited:
Yes
No
Last Name

First Name

Im requesting to do an Observership , please specify:

Sponsoring Institutions Name & Program / Department Rotating From __________________________________________________
Have you participated in an Observership or elective rotation at BIMC in the past?
Yes
Please specify dates at BIMC: from ___/___/____
Month/Day/Year
Does this Observership meet training requirements?

Current training type:

Internship
ECFMG #:___________________ (if applicable)
Former/Maiden Name (If Applicable)

Home Address / Street

E-Mail Addresses:

Yes

Residency
Fellowship
Expiration Date___________
Date Of Birth
____/_____/_______
Apt. #
City

___/___/____

to ___/___/____

Month/Day/Year

Month/Day/Year

Current PGY level: _______________________

HIPAA Trained:
Yes
No

Gender:
Male

City/Country Of Birth
Female
State

Zip

Relationship:
Apt. #

City
Relationship:

Apt. #

City

Languages Spoken

Home Phone

Beeper:

2nd In Case Of Emergency Contact Name:

Address / Street

Month/Day/Year

Specify start and end dates of Obervership rotation

Pager:

1st In Case Of Emergency Contact Name:

Address / Street

No

No
to ___/___/____

Fax Number:

Phone Number (Area Code)

(H) (
)
(W) (
State
Zip
Country

Phone Number (Area Code)

(H) (
)
(W) (
State
Zip
Country

UNDERGRADUATE EDUCATION
Institution Name
Street

City

Degree

Dates Attended:

State/Country

Graduation Date (Degree was Awarded/Conferred) (Month/Date/Year)

Zip/Country Code

From ______/______/_________

To: ______/______/_________

From: ______/______/_________

To: ______/_______/_________

MEDICAL SCHOOL
Institution Name
Street

City

Degree

Dates Attended:

State/Country

Graduation Date (Degree was Awarded/Conferred) (Month/Date/Year)

Zip/Country Code

From ______/______/_________

To: ______/______/_________

From: ______/______/_________

To: ______/_______/_________

INTERNSHIP
Institution Name
Street

City

Program Name/Specialty
H:\BI Incoming 2012\FORMS 2012\Observer Application Form.doc

State/Country

Zip

Dates Attended: From ______/______/_________ To: ______/______/_________

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OBSERVER APPLICATION
University Hospital and Manhattan Campus for Albert Einstein College of Medicine

Did you successfully Complete This Program

Yes No
Anticipated date of Completion
_______/_______/_________

ACGME / ADA Approved

Yes

No

1st RESIDENCY TRAINING

Institution Name
Street

City

State/Country

Program Name/Specialty:
Anticipated date of Completion:

Zip

Dates Attended: From ______/______/_________ To: ______/______/_________

ACGME / ADA Approved: Yes

_______/_______/_________

No

2nd RESIDENCY TRAINING (If Additional Residencies, Please Attach a Separate Sheet)
Institution Name
Street

City

State/Country

Program Name/Specialty:
Anticipated date of Completion:

Zip

Dates Attended: From ______/______/_________ To: ______/______/_________

ACGME / ADA Approved: Yes

_______/_______/_________

No

OTHER RESIDENCY(IES) TRAINING

Institution Name
Street

City

State/Country

Program Name/Specialty:
Anticipated date of Completion:

Zip

Dates Attended: From ______/______/_________ To: ______/______/_________

ACGME / ADA Approved: Yes

_______/_______/_________

No

EXAMINATIONS/LICENSURE
(if you are in an accredited or non-accredited program, license information is MANDATORY if you possess one)
ACLS Certified: Yes
No
Issue Date:______ Expired Date:______
BLS Certified: Yes
No
Issue Date:______ Expired Date:______
License: New York State?
License Number
Yes
No
License Number
Other State/Country Date of Issue

PALS Certified: Yes

Federal DEA Number

Expiration Date

State DEA/CDS (If Applicable)

Expiration Date

Is DEA Number Restricted?

(If Yes, Explain On Attached Page)
Is DEA/CDS Number Restricted?
Yes
No
(If Yes, Explain On Attached Page)
Please provide a copy of your DIPLOMA and CURRICULUM VITAE

Please provide a copy of your ECFMG Certificate:

ECFMG #___________________ Issue Date: _______/_______/_________

No

Issue Date:_______ Expired Date:_______

Expiration Date______/______/______
Expiration Date______/______/______

Permanent
Limited
Permanent
Limited
Yes
No

Temporary
Temporary

OPTIONAL INFORMATION: (For statistical reporting as requested by State and Federal Government agencies.)
Marital Status:

Single

Race/Origin:

Asian

Married

Separated

American Indian

Divorced

Legally Separated

African American/Black

Other, Please Specify: ______________________

Hispanic

Other _____________________
Middle Eastern

White

____________________

As an Observer you are permitted to attend Grand Rounds, Conferences and Observe Procedures. However, you are not
permitted to touch patients or any instruments. In addition, if you are in an operating or treatment room and are
requested to leave by the surgeon/physician at any point, you must do so. I also affirm under the penalty of perjury, that
all information submitted by me in this application is true and accurate. I understand that any significant misstatements
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OBSERVER APPLICATION
University Hospital and Manhattan Campus for Albert Einstein College of Medicine

and/or omissions from the application may be cause for dismissal or denial of appointment. I accept the above
observership conditions and agree that the preceptor will be responsible for the observer.

Print Name Clearly

Observers Signature

Date

Print Name Clearly

Other Institution Chairmans Signature

Date

Print Name Clearly

BIMC Preceptors Signature

Date

Print Name Clearly

BIMC Office of GME Signature

Date

____________________________________________________________
CONSENT AND RELEASE AUTHORIZATION FORM
By submitting this application to become a member of the BIMC House Staff (either as a full time trainee, rotator
or observer), I hereby:
THIS APPLICATION WILL NOT BE PROCESSED UNLESS ALL REQUESTED INFORMATION HAS BEEN FURNISHED

Authorize representatives of Beth Israel Medical Center to consult with representatives of other health care
related facilities with which I have been associated and with others who may have information bearing on
my competence, character, health status, ethics and other qualifications for staff membership and privileges;
Consent to the inspection by representatives of Beth Israel Medical Center of all records and documents that
may be material to an evaluation of my competence, character, health status, ethics and other professional
qualifications for staff membership and privileges;
Release from any liability all representatives of Beth Israel Medical Center including their medical staff(s)
and allied health professional staff(s) for their acts performed and statements made in good faith and
without malice in connection with evaluating my application, credentials and qualifications for staff
membership and privileges, including privileged or otherwise confidential information;
Release from any liability all individuals and organizations who provide information to representatives of
Beth Israel Medical Center and their medical staff(s) and allied health professional staff(s) in good faith and
without malice concerning my competence, character, health status, ethics and other qualifications for staff
membership and privileges, including privileged or otherwise confidential information;
Authorize representatives of Beth Israel Medical Center including their medical staff(s) and allied health
professional staff(s) to provide to health care facilities, medical associations, licensing boards and other
health care related entities any information relevant to me, including otherwise privileged or confidential
information, and release from any liability all representatives of Beth Israel Medical Center
Affirm that all information submitted by me in this application is true to the best of my knowledge and belief,
and I understand that any significant misstatements and/or omissions from the application may be the cause
for dismissal or denial of appointment.

Print Name Clearly

Observers Signature

H:\BI Incoming 2012\FORMS 2012\Observer Application Form.doc

Date
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