Radiation Therapy South Observation Application

Community Health Network offers observation for students who are interested in or need observation hours in radiation therapy. Please complete the form below and you will be contacted to schedule your observation experience.

As of March 14, 2020 Community Health Network is closed to all students and observations due to the COVID-19 outbreak and response. We currently do not have an estimate of when those restrictions will be lifted and will update this page as more information is available. Thank you for your patience as we work together to stop the spread of COVID-19.


Personal Information

Name
Address
One file only.
256 MB limit.
Allowed types: pdf, doc, docx, txt, rtf, jpg.
Please give us a little more information about yourself and discuss any past experiences you have that relate to this internship.

School Information

Is this internship required to graduate from high school?
Is this internship required to graduate?

Objective

Availability

Please select all days you are available:
What time of day do you prefer?
Please enter any dates you are not available for the observation experience.

Immunizations

  • Hepatitis B
  • Rubella (German measles)
  • Rubeola (Red measles)
  • Mumps
  • Varicella (chicken pox)
  • TB skin test (within past 12 months)
  • Influenza vaccine (Flu season: Tuesday after Labor Day through March 31)

Maximum 3 files.
256 MB limit.
Allowed types: pdf, doc, docx, txt, rtf, jpg.

Medical Information

Do you have, or have you had, any of the following?
Check all that apply.
Special Accommodations
Do you require any special accommodations due to medical limitations, disability or other restrictions?
Because of the possible exposure to bodily fluids or the use of x-ray equipment, is there a possibility you may be pregnant?

Emergency Contacts

Acknowledgments and Signatures

Patient Confidentiality

The focus of every patient program is the individual and the family. An individual seeking care at Community Health Network does so with hope, expectations and rights. Since you will be identified with our hospital, please keep in mind these rights:

  1. The patient has the right to personal and informational privacy.
  2. The patient has the right to considerate and respectful care.
  3. The patient has the right to know the identity and purpose of individuals with staff providing services.

The person to whom you are assigned will supervise your observational experience, including asking patients’ permission for you to observe their care/treatment.

Because of the aforementioned patients’ rights, you may not observe or participate in certain activities, including:

  1. Sharing of confidential information except as necessary for the Observational Experience.
  2. Observation of private situations/treatments.
  3. Emergency situations.
  4. Patients in any type of isolation.

You also have the right to decline the observation of any procedure or situation with which you are uncomfortable. You are not to talk about any patient outside the hospital. You may share general information about your observation experience.

I hereby certify that:

  1. I have carefully read and completed the information in the Radiation Therapy Observation Application and my answers and explanations are true, to the best of my knowledge and belief.
  2. I understand that this and other medical information will be held in strict confidence. It will be released only where required by law.
  3. If needed, I consent to the physical assessment by Community Health Network and its agents.
  4. I have read and understand the information on handwashing and the dress code policy. I understand the importance of these during my internship.
  5. I understand the internship will allow me to "shadow" employees within the hospital(s) and/or offsite departments and that this experience is designed to be observational though may involve exposure to health risks such as contact with patients and body fluids. In consideration for participation of the observer in the program and the education and information which the participant will receive, I hereby release, indemnify and hold harmless Community Health Network, its employees, officers and agents from any and all liability arising out of or resulting from participation.
Sign in the box below.
Sign in the box below.

When your application is completed, please press Submit one time. If you do not receive a confirmation screen, please check that you have filled out ALL required fields in the form above and try again. Thank you!