CALIFORNIA STATE UNIVERSITY SAN MARCOS
San Marcos, California 92096-0001
___________________________________________________________
CSUSM Center for Children and Families (CCF)
On-Site and Remote Observation Request Form (Level I)
Observation involves university students observing CCF children through the observation windows
without direct contact.
Requirements: Written permission from the University Liaison to the Center for Children and Families,
adherence to CCF Statement on Dispositions and Observation Requirements, and supervision by a
faculty member or graduate student.
Faculty Name:
__________________________
Department:
Date:
Phone:
Email:
__________________________
Course:
__________________________
# of Students: ___________
Faculty Signature:
REQUEST OBSERVATIONS FOR ____________________SEMESTER
(Fall, Spring, Summer)
On-Site Observation_________
Remote Observation___________
Days______________________
Days________________________
Times_____________________
Times_______________________
Please attach a description of the purpose for the observations and an observation checklist if applicable.
APPROVED
DENIED
Authorized Signature: ______________________
Date:____________________________________
Dr. Maureen Fitzpatrick
Return form to Dr. Maureen Fitzpatrick, University Liaison to the Center for Children and Families
c/o Department of Psychology
Contact: Dr. Maureen Fitzpatrick: mjfitzpa@csusm.edu
Created on 6/30/16