**Bookmark this page in order to complete at a later time**

In order to complete this form make sure you have all of the required documents on hand in order to submit, You will not be able to save this form in order to complete at a later time.

Your visitor application is not complete until the following 3 items are completed/uploaded: 

  1. Proof of health insurance coverage 
  2. Completed immunization record [print form here]
  3. Signed confidentiality pledge

After all required forms are received and reviewed; we will contact you regarding your payment.

* indicate required fields

 

 

 

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Length and Fee of Observership Experience
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1. Mandatory Health Insurance Requirements
International visitors are required to prove they have health insurance coverage that meets the following minimum requirements set by the U.S. Government: $50,000 per accident/illness; $7,500 for repatriation of remains; $10,000 for medical evacuation (return to home country).
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Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png txt pdf doc docx xls.
2. Mandatory Immunization Requirement
To prevent any possibility of risk to patients, staff, and visitors, IJHN requires proof of immunity and health screening for several infectious diseases. Visiting any clinical area will not be permitted until these proofs of immunity and screening are provided.
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Immunizations (or other proof of immunity) are required for Hepatitis B, Measles, Mumps, Rubella (German Measles), Polio, Varicella Zoster (Chicken pox), Tetanus, Diphtheria, and Influenza. PPD screening or other documentation of tuberculosis clearance is required.
Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png txt html pdf doc docx xls xlsx.
3. Mandatory Confidentiality Pledge *Read Carefully*
I understand that while I am visiting in this capacity, I may be exposed to "protected health information," information about a person’s health or treatment that identifies the person, and other information deemed to be confidential by other laws (collectively referred to as “Confidential Information”). I also understand that while I am visiting in this capacity I may be treated as a temporary member of Johns Hopkins’ “workforce” for purposes of the federal HIPAA privacy regulations only. I pledge and agree to use and disclose any Confidential Information only for the training, observational and/or educational purposes of my visit and otherwise to keep the information confidential. The taking of photos, videos and audio recordings is not allowed without additional permissions/authorizations. I will not post or discuss Confidential Information, including pictures and/or videos, on my personal social media sites (e.g. Facebook, Twitter, etc.). I will not access, maintain or transmit Confidential Information on any unencrypted portable electronic devices (e.g. Blackberries, Androids, iPhones, iPads, etc.) and agree to use such devices, with respect to Confidential Information, in accordance with Johns Hopkins policies only. I understand that I may direct to the Johns Hopkins Privacy Office any questions I have about my obligations under this Confidentiality Pledge or under any of the Johns Hopkins’ policies and procedures and applicable laws and regulations related to confidentiality. The contact information is: Johns Hopkins Privacy Office, Telephone: 410-614-9900, e-mail: HIPAA@jhmi.edu.

 I certify that I am visiting Johns Hopkins for observational  purposes only.

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By completing this SIGNATURE field, I warrant my acceptance and adherence to this confidentiality pledge.

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Please type your First and Last Name
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Today's Date
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I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.