Visiting Observer Program Application

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1. Applicant's First Name *

2. Applicant's Last Name *

3. Applicant's Street Address *

4. City *

5. State *

6. Zip Code

7. Country *

8. Contact Email Address *

9. Contact Phone Number *

10. Highest Degree Completed *

11. Which section would you like to visit? *

Body Imaging

Body MRI

Breast Imaging/Breast MRI

Cardiovascular Imaging

Molecular Imaging

Musculoskeletal Imaging

Neuroradiology

Nuclear Medicine

Pediatrics

Thoracic Imaging

Pflichtfrage

12. When would you like to visit Stanford Radiology? ( at least one week, up to 30 days)

12a. 1st Choice of Start Date *

JJJJ

12b. 1st Choice of End Date *

JJJJ

12c. 2nd Choice of Start Date

JJJJ

12d. 2nd Choice of End Date

JJJJ

13. Are you over the age of 18? *

Yes

14. Are you part of any formal education program that would result in a certificate of degree from Stanford University? *

Yes

15. Are you employed by one of the hospitals, e.g. Stanford Health Care or Stanford Children's Health, as opposed to the School of Medicine or Stanford University? *

Yes

16. Are you currently working as a volunteer in any Stanford Health Care facility? *

Yes

17. Are you a member of the media or on staff at any publication? This includes any scientific or academic journals. *

Yes

18. Are you employed by a pharmaceutical or medical device company? *

Yes

19. Please select the option that best describes you: *

International Physician coming to observe a procedure(s)

Domestic Physician/Healthcare Professional coming to observe patient care for education/operations

Community member interested in learning about specific health care career

Community members or other wishing to tour the facility

Medical student coming to observe for educational purposes

Pre-Med/Undergraduate Student

High School Student

Visitor is part of a SU/SoM class that has clinical observation component

Sonstiges:

20. Briefly describe your intended purpose for observing here at Stanford Clinical Hospital/Stanford Health Care? *

** Complete CV required - Please send separately **

Please reply to the confirmation email you receive from Stanford Radiology Visiting Observer Program with your CV attached.

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