CLINICAL MENTOR/SUPERVISOR FORM
Penn Medical Student Activities & Restrictions
Global Health Programs
University of Pennsylvania School of Medicine
423 Guardian Drive: 1007 Blockley Hall
Philadelphia, PA 19104-6021
globhlth@mail.med.upenn.edu
FAX: 1-215-573-2158
We have learned that our clinically-prepared (third or fourth year only) students would like to be involved in a
clinical experience under your supervision and/or mentorship. We are very appreciative of this special
opportunity. However, before we can approve this activity for our students, we require your acknowledgement of
the expectations and limitations (see below) that exist for all of our medical students and we need to know the
specific activities in which the student will engage. Please carefully review the information below, sign, and return
to Global Health Programs as a scanned email attachment, by airmail, or by Fax (contact info above). Many
thanks!
1. Penn medical students are not authorized to engage in healthcare in the capacity of interns,
residents, or medical doctors
2. Penn medical students must use personal protective equipment (PPE) whenever they risk
exposure to blood, body fluids, or airborne pathogens such as tuberculosis; if PPE, including
gloves, respirators, and eye protection, are not provided at your site, students should be
instructed by you/your organization to secure a supply of these items before arriving at your
location
3. If a Penn medical student should experience an exposure to blood or body fluids, the student
must follow the Penn protocol for Post Exposure Prophylaxis (details available on our website:
http://www.med.upenn.edu/globalhealth/travel.shtml#studenthealth)
4. Without appropriate training and supervision, Penn medical students may not perform any
procedures that could expose them to blood or body fluids. Students may perform phlebotomy
and IV placement independently, once they have completed our ITD357 course and they have
been supervised by appropriate healthcare personnel (skilled in these procedures) at your site,
a minimum of 5 times. The student is expected to maintain an electronic log of all procedures
performed, via our student registration system, OASIS.
5. Only with ongoing supervision at your site, by appropriate healthcare personnel skilled in these
procedures, Penn medical students may also perform lumbar puncture, thoracentesis,
paracentesis, joint fluid aspiration, fine needle aspiration, incision and drainage of an abscess,
and skin suturing.
6. Penn medical students must never insert central lines or chest tubes, nor perform
pericardiocentesis or any other procedures not specified above. If you are uncertain about the
permissibility of any given activity, please list on the next page and note level of supervision or
contact us.
Please sign below to indicate your understanding of our students’ restrictions and your willingness to
supervise them, in accordance with these restrictions. On the next page, we also ask that you indicate
the actual level of patient contact the student will have. Many thanks, once again!
Please provide the information requested below and, on the next page, indicate all activities that could involve
exposure to blood or other body fluids that our third and fourth year medical students may engage in while with
your organization. Please check N/A (not applicable) for activities the students will not engage in.
Supervisor Name (Printed)
Supervisor Signature
Supervisor Title (Printed) Please attach brief bio
Organization & Address (Printed)
Mentor/Supervisor Form 02 04 2010
Date
CLINICAL MENTOR/SUPERVISOR FORM – PAGE 2
Penn Medical Student Activities & Restrictions
Global Health Programs
University of Pennsylvania School of Medicine
423 Guardian Drive: 1007 Blockley Hall
Philadelphia, PA 19104-6021
globhlth@mail.med.upenn.edu
FAX: 215-573-2158
Post-Exposure
Prophylaxis
Personal Protective
Equipment
available onsite
student must bring personal supply
Gloves:
available
Eye shields/goggles:
Respirators:
Activity
Notes:
Notes:
student must bring
available
student must bring
available
student must bring
Supervision
Notes (check N/A if student will not
perform)
N/A
Prerequisite* phlebotomies (5)
student will be supervised
Prerequisite* IV placements (5)
student will be supervised
N/A
Independent phlebotomy
Independent IV placement
Lumbar puncture
student will be supervised
N/A
N/A
N/A
Thoracentesis
student will be supervised
N/A
Paracentesis
student will be supervised
N/A
Joint fluid aspiration
student will be supervised
N/A
Fine needle aspiration
student will be supervised
N/A
Incision & drainage of abscess
student will be supervised
N/A
Skin suturing
student will be supervised
N/A
Acupuncture
student will be supervised
N/A
Vaccinations/injections
student will be supervised
N/A
Other:
student will be supervised
N/A
student will be supervised
Other:
N/A
Notes (please describe briefly the scope of what the student will be doing and any potential exposures that the student might have to blood
and body fluids not listed above):
* prerequisite only if the student will move on to independent phlebotomy or IV placement
Completion of the signature section below indicates that you have read page one of this document, describing the
restrictions in place for Penn medical students, that the information above is accurate, and that you accept
responsibility for appropriate supervision of our students. We appreciate your noting full contact information and
title for yourself, as well as professional credentials. If there are any other individuals to whom you may, at times,
delegate this responsibility, please provide the same information for each of them on the next page. Many
thanks!
Supervisor Name (Printed)
Supervisor Signature
Supervisor Title (Printed)
Organization & Address (Printed)
Mentor/Supervisor Form 02 04 2010
Date
Mentor/Supervisor Form 02 04 2010