Request Form for Observation & Learning Experiences
Updated 6/2016
Please complete fields below and select the
button to submit the request to the Office of Observation
and Learning Experience (OLE). The request will be reviewed and a coordinator will respond to the learner
with onboarding requirements and instructions on how to proceed. Incomplete requests may be returned
for completion.
TIP: hover cursor over fields for helpful information
Personal Information of Learner (observer, student, research learner)
Last Name:
First Name:
DOB (month/day/year):
Email Address:
Primary Phone Number:
Alternative Phone Number:
Clear Section
Is the learner a current or former UKHC employee?
Has the learner been processed through this office within the past three years?
Will the learner enter the United States within one year of the anticipated start date?
Request Details
Select the statement that best fits your request:
The learner will be shadowing/observing only, for the purpose specified below (select one):
Required experience for current school or program participation
Personal experience not related to school or program participation
Professional experience to supplement current career in healthcare industry
The learner will be performing activities as part of course credit or degree requirements
The learner will be assisting with research as part of a learning experience
None of the above
If selected “None of the above”, please describe the purpose of the request:
Specify anticipated dates or timeline the learner will be visiting UK HealthCare for their learning experience:
School or Home Institution of Learner (enter “n/a” if not applicable)
School or Home Institution:
Course Name:
Program Name:
Coordinator’s Name:
Coordinator’s Email:
Anticipated Sponsor or Preceptor
* Learners shall be 16 years of age or older to enter an operating room (OR) and the Emergency Department (ED)
Name:
Email:
Phone Number:
Department:
Is the sponsor/preceptor a relative of the learner?
[Additional fields for completion on page 2]
Observation and Learning Experience
UK Good Samaritan Hospital | 310 S. Limestone | Suite B111 | Lexington, KY 40508
859-218-5792 or 859-218-5793
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Request Form for Observation & Learning Experiences
Updated 6/2016
Additional Notations (is there anything else you would like to share regarding this request?)
Requestor Information
What is your relationship to the learner?
 If selected “parent/legal guardian” or “none of the above”, enter your name and contact
information:
Certification
I certify the answers are true and complete to the best of my knowledge. I understand that all required
documentation shall be provided to the Office of Observation and Learning Experience at least 2 weeks
prior to an anticipated start date.
Type your name (qualifies as electronic signature):
Enter today’s date:
Submittal Notifications (the two notifications below will populate after clicking the submit button)
1. Keep the default email and select "Continue"
2. Select “OK”. The form will then be sent to OLE
Submit
Clear Form
Observation and Learning Experience
UK Good Samaritan Hospital | 310 S. Limestone | Suite B111 | Lexington, KY 40508
859-218-5792 or 859-218-5793
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