İZTU International Relations Department

An Observership is an unpaid experience in which a visiting Practitioner (physician, dentist, oral surgeon, or podiatrist) shadows a member of the Medical Staff (the Host Practitioner) in a clinical setting. It may be an opportunity to learn firsthand recent innovations in surgery and medicine, but is not a hands-on clinical experience and is subject to the Clinical Observership Policy (international.tinaztepe.edu.tr )The Observer is to be strictly supervised at all times, shall not be granted independent access to IZTU Medical School and Hospitals facilities and resources, shall not provide any services, and shall not be left unattended at any time. As well, all observers must comply with patient safety and Workplace Health and Safety (WHS) requirements.

The Observer is required to attach the following to the Enrollment Form for review be the Zone Clinical Department (ZCD)

IZTU Confidentiality & User Agreement presented at the end of the online IZTU Information & Privacy and IT Security & Awareness.

Proof of immunization (vaccination record or serologic report) for Rubella.

Criminal Record Check (for experiences longer than 1 week)

The Zone Clinical Department will review and email the approved Enrollment Form and supporting documents to (international@tinaztepe.edu.tr) Medical Affairs will verify and distribute a confirmation memo.

Observer Information

Last Name*

First Name*

Middle Name*

Known As*

Phone Number*

E-Mail*

Observership Information

Host Practitioner Name*

Host Practitioner Phone Number*

Host Practitioner Email Address*

Clinical Department*

Clinical Section*

Clinical Site/Service/Program*

Anticipated Start Date*

Anticipated End Date*

Purpose of Observational Experience*

Please notify international@tinaztepe.edu.tr of any changes to the observership dates. Significant changes or changes to the Host Practitioner may require a new Enrollment Form.

Observer Consent

By signing below, the Observer states that he/she understands the detailed content of the Consent and Confidentiality Agreement on page 2 of this Enrollment form and the Host Practitioner and Zone Clinical Department have reviewed it with him/her.
As well, the Observer understands this position is for ‘shadowing’ only. While in IZTU facilities, you are not permitted to undertake any direct patient care including: history taking, physical examinations, entries into Health Records or access to Patient Care Information Systems.

Consent And Confidentiality (duplicate this page for multiple host practitioners)

IZTU supports opportunities for external Practitioners to observe a host for a defined period. As the IZTU healthcare environment may be unfamiliar, the Host Practitioner and their Zone Clinical Department must ensure that Observer is aware of and complies with the policies, directives and practices (together referred to as “rules”), such as confidentiality and safety.

Please read the following statements that are to be adhered to by the Host Practitioner.

I would like to participate and host an Observer atIZTU MED.
I agree that it is my responsibility that the Observer complies with all policies including confidentiality. I will explain to the Observer that IZTU has a legal and ethical responsibility to safeguard the privacy of all patients/residents/clients and to protecttheconfidentialityoftheirpersonalinformation.MyObserveragreestoabidebytheIZTUpoliciesandprocedures concerning confidentiality and release ofinformation.
I understand that all personal and health information the Observer is privy to is private and confidential. The Observer agrees not to discuss with anyone any individual’s identifying personal or health information that they may come into contact with whileparticipating.
I understand that I may be held responsible for any improper conduct of the Observer, including but not limited to any breach of privacy or confidentiality.
I agree that I will not hold IZTU liable or responsible for injury suffered to the Observer while participating howsoever caused.
I agree to indemnify IZTU for any loss that it may sustain as a result of the Observer’sparticipation.
I understand that in order to participate in the program, the Observer is required to have the Rubella vaccine (German Measles). It is also strongly recommended for the Observer to have the following vaccinations and/or immunizations: Pertussis (Whooping Cough), Tetanus + Diphtheria, Measles, Mumps, Polio, Hepatitis B, Varicella (Chickenpox), Seasonal Influenza and Tuberculosis skin test.

I understand that for observational experiences of duration greater than one (1) week, the Observer shall also be required to provide a criminal record check and vulnerable sectorsearch.

Host Practitioner And Zone Clinical Department Consent

By signing below, the Host Practitioner states they have:

Reviewed the content of this Consent and Confidentiality Agreement with theObserver.
Determined that the clinical area is a suitable environment forparticipation.

Discussed any clinical area specific restrictions regarding participation directly with theObserver.

Approval

By signing below, the manager states they have approved the request based on:

potential risks and IZTU operational needs andconstraints;
environmental factors including workplace health and safety issues;and

impact on and willingness of IZTU representatives (employees, medical staff, trainees, and others) to participate in theexperience.

Pre Application