I, , (the "Observer") acknowledge that I have read, understood and agree to the following terms and conditions:

I understand and agree that when on RVH property, that I must be accompanied by my supervisor at all times. I have read, understood and agree to comply with all applicable rules, regulations, policies and procedures that govern RVH and will refrain from behaving in any way that is unsafe, inappropriate or in contravention of RVH policies, procedures or expectations. I agree to follow all instructions of my Supervisor or other members of the clinical team and acknowledge that failure to do so may result in termination of the Observership at any time.

I agree to conduct myself in a professional, courteous and responsible manner in keeping with the RVH Code of Conduct. I agree to wear an RVH Observer Identification Badge at all times, will be well groomed and will dress appropriately in accordance with the RVH Dress Code Policy #3.040, RVH OHS Scents and Fragrences Guideline 2012 and the RVH OHS Footwear Policy #11.20. I acknowledge that RVH is a completely smoke-free environment and that smoking is not permitted anywhere on RVH property.

I agree to comply with the Personal Protective and Hand Hygiene requirements and have read and understand the Hand Hygiene fact sheet included in the Observership Application package.

Prior to the start of the Observation period, I agree to self-screen myself for communicable diseases and will not enter the Hospital if I answer yes to one or more of the following symptoms: a new cough (not associated with your current illness), fever, shortness of breath, severe headache, unexplained muscle aches, unexplained extreme fatigue, vomiting and/or diarrhea. I agree to leave the hospital if I develop any signs of a communicable illness or otherwise fail the self-screening. Where the Observership will last 7 or more days, I agree to complete a Worker Health Assessment Immunization Record/Respiratory Fit Form.

I agree to strictly guard and maintain the confidentiality of any personal health information, or any hospital administrative information, to which I gain access during this experience. I agree to adhere to and sign the RVH Privacy and Confidentiality Agreement and not to, under any circumstance, access financial, human resources and other confidential records of RVH.

I understand that as an Observer, I am not considered a member of the staff or an employee, nor am I an independent contractor of RVH and therefore I am not entitled to salary, benefits, reimbursement of expenses or other forms of compensation. Furthermore, I understand that I am not covered under the Workplace Safety and Insurance Board (WSIB) or covered under RVH’s liability insurance. I understand that I am not entitled to receive educational credit or certification from the RVH for time spent observing and that I am not entitled access to RVH Occupational Health and Safety (with the exception of status testing for TB).

I agree not to provide medical care to patients during the Observation period. I understand that medical care includes, but is not limited to the following functions: interacting with patients or families beyond introductions; taking a medical history; conducting physical examinations; diagnosing or treating a patient’s condition; ordering, preparing or administering drugs; performing or assisting in procedures or interventions; obtaining consent; writing notes or orders in a patient’s health record, either in electronic or hard copy format; manipulating any equipment used in patient care; accessing health records, either in electronic or hard copy format; and providing health care advice. I further acknowledge that providing medical care to patients in violation of this Agreement may result in civil liability, licensing sanctions, or criminal penalties.

I acknowledge that I will respect patient confidentiality and that I will not discuss any patient, his/her medical history, or his/her reason for being at RVH with anyone other than the Supervisor. Under no circumstances will pictures and/or recordings of any nature, including pictures and/or recordings of patients, visitors, staff, physicians, volunteers, records, equipment or facilities, be permitted anywhere in RVH. I acknowledge that I will not access patient charts or patient information, in any format.

I understand and agree that there is no guarantee that I will be able to observe all patients and treatments. I understand that I am only permitted to attend selected patients when accompanying my Supervisor and at no other time. I understand that any patient, at any time, may decline to have me observe in their care. I will ensure that each patient verbally consents to my presence during the Supervisor’s visit prior to me observing any patient care activities. I will remove myself immediately from the patient area if asked to do so at any time, for any reason, by any member of the RVH staff and/or Professional Staff.

I understand that RVH may terminate the Observership at any time and in its sole discretion. I acknowledge that I may be required to leave the premises immediately should the Observation period be terminated by RVH. I understand that no appeal or grievance rights exist to challenge the termination of an Observership.

I am aware that as a result of the observation of the Supervisor, I may be exposed to certain risks and dangers inherent in the workplace. In consideration of RVH approving my participation in the Observership, I agree for myself, my heirs, next of kin, executor(s), administrator(s) and personal representative(s) to hereby release and forever discharge RVH, its officers, trustees, principles, directors, employees and agents, as well as the Professional Staff, from any and all actions, claims and demands for damages, loss and injury, howsoever arising which now or may hereafter be sustained by me out of or in consequence of my participation in the Observership. For the same consideration, I agree to indemnify RVH, its officers, directors, employees and agents from any and all claims and demands which might be made against RVH, its officers, directors, employees and agents arising out of or in consequence of my participation in the Observership.

I understand that a complete Observership Application must be received by the Academic and Medical Affairs Office a minimum of two weeks in advance of the requested Observership in order to be considered. I understand I may not participate in an Observership without all of requirements of the Observership Agreement being completed and in place. I acknowledge and understand that under no circumstance may I be permitted to enage in any Observership activities outside of the dates approved by the Academic and Medical Affairs Office. I acknowledge that all RVH equipment or property, including scrubs and ID badge, must be returned at the end of the Observership.