ACADEMIC AFFAIRS – MEDICAL EDUCATION

STUDENT OBSERVER REGISTRATION FORM

FROM: Martha Bustamante, Ext 14541 Duque Bldg., 1st Floor, #1-294 Mail Stop #71
COORDINATOR INSTRUCTIONS:
  1. Fill the Student Observer Registration Form out completely.
  2. Observer is cleared ONLY for your division
  3. After ending date, a new form must be completed to extend and accompanied with immunization records.
  4. After all signatures have been obtained, student is to provide ORIGINAL to the division coordinator for their records.
  5. SCAN and email ONLY THIS FORM to:

To be completed by Coordinator

Section I:

OBSERVER NAME: CHLA ID#:

(To be entered by Coordinator)

Email:Home # or Cell #:

(circle one)

Name of affiliating institution/school: USC or Other:

Name of Supervising Physician:

NO PATIENT CONTACT Training Status (check one):

□0268 – Student / Physician Observer□0273 –Student / Physician Observer than 30 days;

Lessthan 30 days Med Peds 490, USC Pre-Health (Dr. Geller)

& other affiliated programs

□2029–Grad Student than 30 days

UCEDD & other affiliated programs

□ 0265 –KSOM Research Observer than 30 days

SABAN Research Observer

To be completed by Coordinator

Section II:

Dept.: Academic Affairs

Division:Bldg:Elevator: Floor:

Flu Vaccination: Date of Current PPD:

(Must be noted) (Must be noted)

Dates approved for training: From: To:

Ending date cannot exceed PPD expiration date

Academic Affairs: Date:

(Page Bldg, Room 1-294)Signature

Health Clearance Form Complete: Date:

(Verified by Coordinator)Signature

Parking & ID Office: Date:

(look for blue hand rail for entrance) Signature

(Directly across the street, 4601 Sunset Blvd.)

OFFICE OF ACADEMIC AFFAIRS – MEDICAL EDUCATION

Must be completed & submitted byDivision Coordinator

and e-mailed to: .

This form is to be used to request HR issued PeopleSoft employee ID numbers for non-employees only(staff not on CHLA payroll).

student observer

Non-Employee PeopleSoft ID Request FORM

INFORMATION MUST BE TYPED

*= required fields

*Today’s Date:
*Start Date: / *Social Security #:
*Name:
*Please provide full name: First Middle (if applicable) Last
E-Mail Address: / *Gender:
*HR Dept ID # / Name:310020M071
Academic Affairs-Students (CWR) / *Supervisor’s Name: Martha Bustamante
; Ext. 14541
Assigned Department/Division (may only report to one)
Indicate actual department/division reporting to: / Reports To:Name of supervising physician
*End Date Ending date cannot exceed PPD expiration date:

*Classification (check ONLY one):

000268 / Student /Physician Observer
LESS than 30 days / 000273 / Student Observer / Physician Observer
MORE than 30 days
(Meds-490, USC Pre-Health - Dr. Geller
other affiliated programs)
002029 / Grad Student (UCCED, other affiliated programs )
MORE than 30 days
002065 / KSOM Research Observer
MORE than 30 days

OFFICE OF ACADEMIC AFFAIRS – MEDICAL EDUCATION

Must be completed & submitted byDivision Coordinator

and e-mailed to: .

This form is to be used to request HR issued PeopleSoft employee ID numbers for non-employees only(staff not on CHLA payroll).

research observer

Non-Employee PeopleSoft ID Request FORM

INFORMATION MUST BE TYPED

*= required fields

*Today’s Date:
*Start Date: / *Social Security #:
*Name:
*Please provide full name: First Middle (if applicable) Last
E-Mail Address: / *Gender:
*HR Dept ID # / Name:310020M071
Academic Affairs-Students (CWR) / *Supervisor’s Name: Harleen Gill
; Ext. 18626
Assigned Department/Division (may only report to one)
Indicate actual department/division reporting to: / Reports To:Name of supervising physician
*End Date Ending date cannot exceed PPD expiration date:

*Classification (check ONLY one):

000264 / Research Observer
LESS than 30 days / Definition: Only conducts bench research or analyzing data. Not allowed to interact
with human research subjects such as for the purpose of a survey study.
000265 / Research Observer
MORE than 30 days / Definition: Only conducts bench research or analyzing data and are here for30 days or
more. Not allowed to interact with human research subjects such as for the purpose of
a survey study.

OFFICE OF ACADEMIC AFFAIRS – MEDICAL EDUCATION

Must be completed & submitted byDivision Coordinator

and e-mailed to: .

This form is to be used to request HR issued PeopleSoft employee ID numbers for non-employees only(staff not on CHLA payroll).

rotating resident – rotating fellow

Non-Employee PeopleSoft ID Request FORM

INFORMATION MUST BE TYPED

*= required fields

*Today’s Date:
*Start Date: / *Social Security #:
*Name:
*Please provide full name: First Middle (if applicable) Last
E-Mail Address: / *Gender:
*HR Dept ID # / Name:310020M071
Academic Affairs-Students (CWR) / *Supervisor’s Name: Martha Balladares
; Ext. 15584
Assigned Department/Division (may only report to one)
Indicate actual department/division reporting to: / Reports To:Name of supervising physician
*End Date Ending date cannot exceed PPD expiration date:

*Classification (check ONLY one):

002031 / Rotating RESIDENT
LESSthan 30 days / 002034 / Rotating FELLOW
LESS than 30 days
002069 / Rotating RESIDENT
MORE than 30 days / 002070 / Rotating FELLOW
MORE than 30 days