350 Boulevard Passaic  NJ 07055  973-365-4300

Medical Staff Office – Phone: 973-365-4410 – Fax: 973-365-4599

Physician Observer Application

Thank you for your interest in applying for Physician Shadowing Authorization. Enclosed you will find and
Application. It is critical that you take the time to answer all questions and submit all requested information
completely and accurately. We will not accept an incomplete application or the comment “see CV”.

Information/documentation to be included with your completed application:

Application Fee (non-refundable) of $25 made payable to St. Mary’s General

Hospital (Applications submitted without an accompanying fee will not be accepted
for processing)
Recent 2x2 color photo
Current copy of your CV/Resume
Health Certificate completed by your physician (all sections must be complete)
HIPAA Form
Observer Form
Code of Conduct Form
Background Investigation Release
Copy of Medical Staff Privileges at Primary Hospital, if applicable
Copy of Certification, if applicable

Upon receipt of your completed application and accompanying documentation, we are mandated to verify
key information.

Once your file is complete, you will be contacted to interview with the VPMA and/or Medical Staff Officer.
You will be formally notified of a decision.

Again, thank you for your interest. If you have any questions about the application or the credentialing
process, please contact the Medical Staff Office at 973-365-4410.

Sincerely,

Atul Prakash, MD
Atul Prakash, MD
President, Medical/Dental Staff

Revised 8-16-16
 Physician Observer Application

Name Phone

Social Security # DOB

School Name and Location

Name of Physician to be observed

Department Section
( ) Proctoring ( ) Other, explain below
Reason for observation

Period Requested
(Not to exceed 90 days)

Applicant Signature Date

FOR ST. MARY’S USE ONLY

 Application Complete  Proof of ID  Delineation of Privileges
 Health Cleared  Background Check Cleared  Certification
 Observer Agreement  Code of Conduct
The above Physician Observer will be under my direct control and supervision. I will schedule
orientation with the area’s Manager to include dress code, infection control overview and traffic
patterns and a tour of the changing areas and Operating /Procedure Rooms.

Physician Signature Date

Please collect photo ID from the Observer at the end of the approved period. This ID must be returned
to the Medical Staff Office.

Dept Chair Signature Date

VPMA/MS Officer Approval  Yes  No

Signature Date

SECURITY:
The above Physician Observer has been approved to observe Dr. ______________________.
The approval is valid until _________________________.
 OBSERVER’S AGREEMENT

I recognize that during the course of observing surgical procedures in the Procedural Room, I may obtain
individually identifiable health information of the patient under observation. I agree to keep all such
information and information regarding patient care confidential. I agree not to use or cause to be used or
disclose to another person, any patient’s individually identifiable health information. This shall be true
regardless of how I learn of such information.

For the purpose of this Agreement, “individually identifiable health information” shall include any
information (including demographic information) collected from or about an individual that:

A. is created or received by a health care providers;

B. Relates to the past, present, or future physical or mental health or condition of an individual, the
provision of health care to an individual, or the past, present, or future payment for the provision of
health care to an individual; and
C. Either
i. identifies the individual, or
ii. contains information that can be used to identify the individual

I agree and acknowledge that I will be under the supervision and direction of the surgeon at all times while I
am in the Procedural Room, and agree to abide by and comply with all directives given me by the surgeon.

I agree and acknowledge that I am in the Procedural Room at my own risk and hereby release St. Mary’s
Hospital and their trustees, officers, employees and agents from any liability, claims, loss and expenses of
any kind arising in relation to my presence in the Procedural Room. I further agree to indemnify and hold
harmless St. Mary’s Hospital and their trustees, officers, employees and agents from and against any and all
claims and liabilities (including reasonable attorneys’ fees and expenses incurred in the defense thereof)
resulting from or attributable to (1) any and all of my negligent or intentional acts or omissions while at the
Hospital or (2) my failure to abide by the confidentiality agreement set forth above.

Print Name:

Signature: Date:
 OBSERVER CODE OF CONDUCT

When observing a physician, I will:

1. Arrive promptly.
2. Accurately represent my position and role
3. Appreciate the limits of my role as an observer by not engaging in activities like, but not limited to,
diagnosing diseases, administering medications, performing surgical procedures, suturing, providing
medical advice or other tasks generally reserved for the trained health professional.
4. Respect patients’ rights to refuse to have students present.
5. Treat all patients and staff with respect and dignity, regardless of age, gender, race, ethnicity, national
origin, religion, disability or sexual orientation.
6. Maintain strict confidentiality and privacy about patient information.
7. Maintain honesty and integrity by being forthright in my interactions with patients, peers, physician
supervisors and staff.
8. Ensure patient safety by remaining at home if I am ill; and will notify physicians of my planned
absence.
9. Report concerns about patient safety to the physician who is being observed.
10. Behave in an appropriate, professional, courteous manner at all times.
11. Not initiate or accept patients’ invitations to engage in social or social media relationships.
12. Dress and act professionally.
13. Not abuse drugs or alcohol.
14. Be aware of and follow the guidelines of my sponsoring institution and of the setting in which I am
an observer.

I agree to follow the Code of Conduct described above.

Print Name:

Signature: Date:
 CONFIDENTIALITY AND PRIVACY OF
PATIENT INFORMATION

Dear Observer,

As an observer who is rotating in this health care setting and office practice, you have an ethical and legal
duty to keep patient information confidential. Federal law known as the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) allows health care providers to use and disclose patient information for
certain reasons, such as treatment, but at times it is necessary for the patient to agree to have his/her
information used or disclosed. Health care providers also must consider who has access to the information
and how much they need to see. Observing an encounter between a provider and a patient requires patient
authorization. Failure to maintain the confidentiality of patient information as required by HIPAA is
considered a violation of the law and may have serious consequences.

Some general guidelines:

 Access patient information only under the direction and supervision of the health care provider you
are observing.
 Share or discuss patient information only when necessary and only in locations where the
confidentiality of that information can be maintained.
 Patient information should never be disclosed in any form of social media.
 Be familiar with and follow the health care system and provider’s policies on confidentiality and
privacy.
 Should you have any questions or concerns, discuss them wit the physician you are observing.

Read and understood

Print Name:

Signature: Date:
 AUTHORIZATION AND RELEASE OF INFORMATION

By submitting this Application, including all subparts and attachments, I hereby acknowledge, understand,
and consent and agree to the following:

 As an applicant for observing at St. Mary's Hospital I herby authorize representatives of St. Mary's
Hospital and its Medical Staff to consult with members of the medical staffs of other hospitals with
which I have been associated and with others who may have information bearing on my competence,
character, health status, ethics and other qualifications for observing ;
 Consent to inspection by representatives of St. Mary's Hospital and its Medical Staff of all records
and documents that may be material to an evaluation of my character, health status, ethics and other
qualifications for Observing;
 Consent to have a background investigation made as to my criminal record;
 Release from any liability all representative of St. Mary's Hospital and its Medical Staff for their acts
performed and statements made in good faith and without malice in connection with evaluating my
application, credentials and qualifications for Observing;
 Release from any liability all individuals and organizations who provide information to
representatives of St. Mary's Hospital and its Medical Staff in good faith and without malice
concerning my character, health status, ethics and other qualifications for Observing, including
otherwise privileged or confidential information;
 Agree to waive any confidentiality provisions concerning the information required to be provided to
representatives of St. Mary's Hospital and its Medical Staff in evaluating my application for
Observing;
 Authorize and consent to representatives of St. Mary's Hospital and its Medical Staff providing other
hospitals, medical associations, licensing boards and other organizations concerned with provider
performance and the quality and efficiency of patient care with any information relevant to such
matters that St. Mary's Hospital may have concerning me including otherwise privileged or
confidential information, and release all representative of St. Mary's Hospital and its Medical Staff
from liability for so doing provided that such furnishing of information is done in good faith and
without malice;
 Acknowledge that I have the burden of producing the information and materials requested for proper
evaluation of my character, health status, ethics and other qualifications for Observing for resolving
any doubts about such qualifications;
 Acknowledge that any significant misstatements in or omissions from this application shall constitute
cause for denial or summary dismissal from Observing.

Print Name:

Signature: Date:
 HEALTH CERTIFICATE

Applicant Name: ______________________________________ SS#:_____________________

(Last, First, MI)

Address: _______________________________________________________________________
(Street, City, State, Zip)

Telephone Number: (______) ____________________ DOB: _______/_______/________

1. Measles, Mumps, Rubella, and Varicella: The CDC defines immunity to these viruses as one of the
following: (1) Appropriate immunization*, (2) positive titer, diagnosed case of the illness. Given the
above definition of immunity, please complete the following information for this individual.
VACCINE: Dates of each injection or exposure.
Measles: Yes_____ No_____ Mumps: Yes_____ No_____
Rubella: Yes_____ No_____ Varicella: Yes_____ No_____
*Measles, Mumps, and Rubella Vaccine (MMR): Two doses of live measles (or MMR) vaccine, at least one month apart, on or after his/her first birthday.
Varicella Vaccine: Individuals who receive the vaccine between 12 months and 12 years of age are required to only receive one dose of the vaccine.
Individuals over the age of 13 should receive two doses of the vaccine 4 to 8 weeks apart. If unsure of immune status, please have titers done.
2. Hepatitis B Vaccine: If you have given this patient the Hepatitis B vaccine, please record the dates
that it was given.
1st dose _____/_____/_____ 2nd dose_____/______/_____ 3rd dose_____/_____/_____

3. Tuberculosis Testing: If you have ever placed a Mantoux Test (PPD) on this patient, please record the
two most current test dates and results. If positive, please provide documentation of a chest x-ray.
Date: mo/date/yr Amount Result (mm)

1._________________________________________________________________________
2._________________________________________________________________________

4. Health Status: To my knowledge this applicant:

a. Is free from contagious disease and capable of performing all volunteer assignments.
Yes______ No______

b. If no, please list what precautions need to be taken and if the volunteer has any restrictions in her or
his activities: __________________________________---_______________________________
__________________________________________________________________________________
5. Doctor’s Name:_____________________________ Doctor’s
signature:________________________

6. Doctor’s Address:___________________________________________________________________
 Employee Health Services
350 Boulevard Passaic, NJ 07055
Tel. (973) 365-4501 Fax (973) 365-4641

HEPATITIS B VACCINE ACCEPTANCE/DECLINATION FORM

Declination (Do not Want)

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at
risk of acquiring hepatitis B (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B
vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand that by
declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue
to have occupational exposure to blood or other potentially infectious material and I want to be vaccinated with
hepatitis B vaccine, I can receive the vaccination series at no charge to me.

Name: ______________________________________________________________________________
(Please Print)

Signature: ___________________________________________________________________________

Department: __________________________________ Date: ____________________________

Hepatitis B Vaccine Acceptance

I want to receive the Hepatitis B Vaccine. I understand it is my responsibility to contact Employee Health Services
for an appointment.

Name: ______________________________________________________________________________
(Please Print)

Signature: ___________________________________________________________________________

Department: __________________________________ Date: ____________________________

PREVIOUS Immunization or Disease

History of Hepatitis B disease: Yes ____ No ____ Year ___________

History of Vaccine: Yes ____ No ____ Year ___________

Number of Immunizations/doses _________________________________________

Name: ______________________________________________________________________________
(Please Print)

Signature: ___________________________________________________________________________

Department: __________________________________ Date: ____________________________

 Employee Health Services
350 Boulevard Passaic, NJ 07055
Tel. (973) 365-4501

Please Forward Results to the Medical Staff Office

Tel. (973) 365-4410
Fax (973) 365-4599

Tuberculin Skin Test/TST

PRINT NAME: ___________________________________________________________________________

DATE OF BIRTH: _____________________________

DEPARTMENT/SPECIALTY: _____________________________________________________________

DATE TST PLACED: _______________________ SITE: RIGHT LEFT FOREARM

MANUFACTURER: [ ] Sanofi Pasteur Limited Other_______________________________________

LOT: ____________________ EXPIRATION DATE: _______________ DOSE: 5 TU ID

PLACED BY: ____________________________________________________________ (SIGNATURE)

____________________________________________________________ (PRINT NAME)

(Must Be Place By Licensed Physician or RN)

MUST BE READ IN 48 OR 72 HOURS

DATE TST READ: ___________________ 48 HOURS or ________________________ 72 HOURS

RESULTS: ___________________________ mm (INDURATION)

**** Must Be Read in MM a “negative” or “positive” is not acceptable****

READ BY: ____________________________________________________________ (SIGNATURE)

____________________________________________________________ (PRINT NAME)

(Must Be Place By Licensed Physician or RN)

*** Positive results, 10mm or more (induration) will need to be evaluated further***

MANTOUX TESTING IS REQUIRED FOR EMPLOYMENT BY

THE NEW JERSEY STATE DEPARTMENT OF HEALTH AND ST. MARY’S GENERAL HOSPITAL
POLICY
 Employee Health Services
350 Boulevard Passaic, NJ 07055
Tel. (973) 365-4501 Fax (973) 365-4641

TUBERCULIN SKIN TEST EXEMPTION QUESTIONNAIRE

1. Please indicate reason for completing this form:

[ ] TB Exposure
[ ] Prior Positive TST
[ ] Cortisone/Prednisone/Immunosuppressive Drugs
[ ] T.B. Medication – Specify: _____________________________________________

____________________________________________________________________

2. Have you experienced any of the following in the past year?

YES NO

Fever [ ] [ ]
Night Sweats [ ] [ ]
Weight Loss (Unintentional) [ ] [ ]
Malaise [ ] [ ]
Fatigue Easily [ ] [ ]
Cough [ ] [ ]
Coughing-up Blood [ ] [ ]
Coughing-up Greenish Sputum [ ] [ ]
Painful/Tender Lymph Nodes [ ] [ ]
Chest Pain on Breathing [ ] [ ]
Difficulty Breathing [ ] [ ]

If you should experience any of the above symptoms prior to your next screening, contact Employee
Health Services promptly at Ext. 4501.

If anti-Tuberculosis medication has been ordered for you, be sure that you do not stop taking it except
on the instruction of your physician.

_______________________________ ______________________________
Print Name Department/Unit Extension

_______________________________ ______________________________
Signature of Employee Date

________________________________ _______________________________
Signature of Reviewer Date
 PASSAIC, NJ

DEPARMENT OF EMPLOYEE HEALTH SERVICES POLICY

INFECTION CONTROL

TUBERCULOSIS TESTING & FOLLOW UP

I. PURPOSE:

To evaluate healthcare workers for TB infection or Disease at time of employment, annually and after an
occupational exposure and to arrange for appropriate follow-up when indicated.

II. POLICY

It is the policy of St. Mary’s General Hospital that all healthcare workers must comply with the TB screening
and skin testing policy in order to begin employment or to continue with employment at St. Mary’s General
Hospital. Employees non-compliant with testing may be removed from work without pay until testing is
completed.

III. DETECTION OF TUBERCULOSIS

A. Skin Tests – Newly hired healthcare workers

1. All new healthcare workers (full and part time) shall be given a two-step Mantoux Tuberculin Skin Test
with five tuberculin units of purified protein derivative (PPD/TST) intradermally one to three weeks apart.

The only exceptions are healthcare workers with documented negative Mantoux skin test results (zero to
nine millimeters of induration) within the last year, healthcare workers with documented positive Mantoux
skin test results (0 or more millimeters of duration), healthcare workers who received appropriate medical
treatment for tuberculosis, or when medically contraindicated.

2. If the second Mantoux Tuberculin Skin Test is negative, the test shall be repeated annually for as long as
the reaction to the test remains negative.

3. If the first or second Mantoux Tuberculin Skin Test reaction is 10mm or more of induration, a chest x-ray
shall be performed. The healthcare worker will be referred to his/her private physician, or the appropriate
chest clinic for a medical evaluation. They will determine whether there is evidence of latent tuberculosis
infection, or active tuberculosis disease. The healthcare worker must submit written medical clearance
from his/her primary physician or county chest clinic to Employee Health Services to begin working. This
documentation will be kept in the employee’s medical file in Employee Health Services. If a female
employee requires a chest x-ray and is ten days past her menses, a urine pregnancy test will be done.

If the first TST/PPD is positive and a chest x-ray is not obtainable due to late menses or the possibility of
pregnancy, the healthcare worker needs to submit written medical clearance before being permitted to
work. The healthcare worker will be referred to his/her private physician, or appropriate chest clinic for a
medical evaluation to determine whether there is evidence of latent tuberculosis infection or active
tuberculosis disease.

4. A healthcare worker will not be cleared to begin work until after the two step Mantoux Tuberculin Skin
Test is completed and documented in the Employee Health Services medical file. The employee will be
advised in writing that they must comply with the requirement to have a second TST/PPD done within one
(1) to three (3) weeks of the first PPD. If the Mantoux is positive, refer to Section III, A 3.
 If the healthcare worker has a positive Mantoux reading and a positive chest x-ray, the
Healthcare worker will not be issued a medical clearance until documentation is received from their
own physician or chest clinic indicating that he/she does not have active Pulmonary TB and is not
infectious.

B. Skin Test After BCG Vaccination

1. Healthcare workers who have had prior BCG vaccination, will be skin tested using the Mantoux
method, unless previously significant reaction has been documented.

2. The results of skin tests in persons who have prior BCG vaccination should be interpreted and
acted on in the same manner as those personnel who have not been vaccinated with BCG.

C. Skin Tests – Annual Requirement

1. An annual Mantoux skin test for all tuberculin negative healthcare workers is required. Based on
the annual hospital risk assessment, healthcare workers working in designated high risk area may
be required to have a bi-annual skin test.

2. The only permissible exclusions from pre-employment or follow-up annual Mantoux skin testing
are:
a. people with a previously documented positive reaction to tuberculin testing (10) ten or more
millimeters of induration.
b. people with documented previous or present adequately treated TB disease; or
c. people who completed adequate preventive therapy.

People excluded from skin testing due to a prior positive test or past TB disease, must be
evaluated annually for active disease by completing the “Mantoux Tuberculosis Skin Test
Exemption Questionnaire.”

IV. FOLLOW-UP

A. Significant Reactions

All healthcare workers with significant reactions must be informed about the risks of developing
disease, and the risks they may pose to their contacts as well as preventative treatment.

B. Chest Roentgenograms

1. Chest Roentgenograms will be taken on those persons with significant tuberculin skin test results:
a. Who have never been evaluated.
b. Who have had recent conversions.
c. Who have never received adequate treatment for tuberculosis.
d. Who have pulmonary symptoms that may be due to tuberculosis.

If the chest film suggests pulmonary TB, these persons should be evaluated to rule out
the possibility of current disease. They will not be permitted to work until their PMD or
chest clinic certifies that the healthcare worker is not infectious.

2. Chest x-rays will be done at time of conversion and if the healthcare worker becomes
symptomatic, every six months for one year and then every two years.
 3. Healthcare worker having positive tuberculin skin test with negative chest x-rays shall be
assessed annually for symptomatology and advised to report pertinent symptomatology
immediately.

V. PREVENTATIVE TREATMENT

A. The following are person for whom preventive treatment is recommended:

1. Newly infected persons.

2. Significant reactors with abnormal chest x-rays and negative bacteriologic findings.
3. Persons with special clinical conditions.
4. Significant reactors less than 35 years old, even in the absence of additional risk factors.
5. New diagnosed employees will be advised that all household members and other close contacts
should be evaluated by their personal physician.
6. Person’s age 35 years or more who have recently converted shall be evaluated on an individual
basis by their personal physician or the appropriate chest clinic.

B. Post-exposure Testing & Follow Up

1. Healthcare workers exposed to patients with infectious Pulmonary TB (defined as a patient with a
positive direct and/or concentrated smear) for whom adequate infection control procedures have
not been taken need a Mantoux skin test as soon as possible unless the healthcare worker has had
a negative skin test within the preceding 3 months or if he/she has had a previously documented
positive skin test reaction. If the skin test is negative, it should be repeated 12 weeks after the
exposure.

2. Exposed healthcare worker with skin test reactions or with symptoms suggestive of TB should
have a chest x-ray and medical evaluation and follow-up as indicated.

3. Healthcare workers with previously documented positive skin test reactions must:
a. Complete a “Mantoux Tuberculosis Skin Test Exemption Questionnaire.”
b. A repeat Mantoux is not required
c. A chest x-ray may be performed if requested by the healthcare worker.
d. These healthcare workers will be instructed to notify Employee Health Services if they
experience any symptoms suggestive of TB.

VI. WORK RESTRICTIONS

A. Healthcare workers with suspected or proven TB disease

1. Healthcare workers with active pulmonary or laryngeal TB must be excluded from work
until:

a. adequate treatment is instituted;

b. cough is resolved;
c. a physician certifies the healthcare worker is no longer infectious.
 2. Documentation of the above conditions should be provided to the Employee Health
Services before the healthcare worker returns to work.

3. Healthcare workers with tuberculosis at sites other than the lung or larynx usually do not
need to be excluded from work if concurrent pulmonary tuberculosis has been ruled out.

4. Healthcare workers who discontinue treatment for pulmonary or laryngeal TB before the
recommended course of therapy has been completed will not be allowed to work until:

a. Treatment is resumed;
b. an adequate response to therapy is documented;
c. physician certifies that treatment is complete.

B. Healthcare workers receiving Preventive Therapy

1. Healthcare workers who are otherwise healthy and receiving preventive treatment for
tuberculosis infection should be allowed to continue his/her usual work activities.

2. Healthcare workers who cannot take or do not accept or complete a full course of
preventive should have their work situations evaluated. Work restrictions may not be
necessary for otherwise healthy people who do not accept or complete preventive
therapy. These people should be counseled about the risk of developing active disease
and should be instructed to seek evaluation promptly if symptoms develop that may be
due to tuberculosis.

VII. CHARTING ON THE HEALTHCARE WORKERS MEDICAL RECORD

1. Date TST/PPD was administered and by whom, site, lot number, expiration date and
manufacturer.

2. Date and time read (48-72 hours) and by whom.

3. Test results must be read and recorded in “millimeters” of induration (palapable hardness).
Test results recorded as just “positive” or “negative” are not acceptable.

4. Medical Records should indicate when a healthcare worker has a newly converted skin test, a
negative chest x-ray and has no symptoms of pulmonary TB that he/she may continue with their
assigned work responsibilities.