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Nurse Observership Application Form

Department of Pain Medicine and Palliative Care

Beth Israel Medical Center

Name:	_______________________________________________________________________________
Degree(s):	_______________________________________________________________________________
Mailing Address:	_______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________
Telephone:	_______________________________________________________________________________
Fax:	_______________________________________________________________________________
Discipline:	_______________________________________________________________________________
Specialty:	_______________________________________________________________________________
Position/Hospital Affiliation:	_______________________________________________________________________________
Office Address:	_______________________________________________________________________________
Office Phone:	_______________________________________________________________________________

Describe current areas of work/interest/research:

_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

Describe current educational activities:

Describe areas of interest that you wish to pursue through the observership:

List potential mentors:

List dates which you would prefer for observership (somewhat flexible):

Please indicate number of days desired at Beth Israel. Every effort will be made to accommodate this request and match interests with faculty specialties:

Please attach the following:

1.	A copy of your curriculum vitae
2.	One letter of reference indicating support from your institution. This should propose future educational activities which you may initiate as a result of participation in the observership.

Please forward items to:

Myra Glajchen, DSW
Department of Pain Medicine and Palliative Care
Beth Israel Medical Center
1st Avenue at 16th Street
12 Baird Hall
New York, New York 10003
Tel: 212-844-1472
Fax: 212-844-1503

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