Global Education & Training

Houston Methodist Global Health Care Services

6560 Fannin St. Suite 570

Houston, Texas 77030
Office: 713-441-2340

PRECEPTOR SUPERVISION OBSERVERSHIP AGREEMENT

Preceptor Information
By signing this agreement, I, ________________________________
Nina Bryant-Sanyika in ____________________________________
Spiritual Care & Education Department having
Preceptor Name Department/Service

institutional privileges at Houston Methodist Hospital, will allow ________________________ to shadow me between
_________________
5/3/2023 -- _________________
5/3/2023 . Observer Name
Start Date End Date
Observership Benefit
In the section below, describe the benefits of this activity and its impact to Houston Methodist.

Cultural Exchange Program between HMH and Mexico Wesley Seminary

Observership Policies
 I understand that the observer will accompany only me while I am on duty and will comply with the observer policy
currently in place. (Copy attached)
 I will ensure that the observer has no physical or verbal direct patient contact, aside from general greetings and
introductions (independent direct patient contact is strictly prohibited).

Patient Information
 I understand that the observer will not have independent access to patient information which includes access to ANY
electronic health records or system applications.
 I will ensure that the observer complies with all Houston Methodist policies and procedures, including patient
confidentiality and applicable provisions of federal, state and local law, including the Health Insurance Portability and
Accountability Act (HIPAA).

Termination
 I understand that either I or Houston Methodist may, at their sole discretion, terminate this experience at any time.

Read, understood and agree to comply by

Role Printed Name Signature Date

Preceptor Nina Bryant-Sanyika
Department Administrator/
Education Manager Luis E. Rodriguez 4/27/2023

APPLICANT OBSERVERSHIP AGREEMENT

 I understand that I must be vaccinated with all required vaccines before beginning the observership program.
 I agree to practice good personal hygiene by washing my hands often and wear a face covering properly.
 I understand it is not permitted to have physical or verbal direct patient contact, aside from general greetings and
introductions (independent direct patient contact is strictly prohibited).
 I understand I am not allowed to have independent access to patient information which includes access to ANY
electronic health records or system applications.
 I understand that Houston Methodist may, at their sole discretion, terminate this experience at any time.

Read, understood and agree to comply by Observer

Applicant Printed Name Signature Date