RESPIRATORY CARE PROGRAM
Applicant Documentation of Completion of
A Respiratory Care Department Observation Experience
TO THE APPLICANT: To ensure a realistic understanding of what the profession is like, direct observation
of professional respiratory therapist duties in both critical care and non-critical care environments in an
acute care hospital is required as part of the Respiratory Care Program application process.
Any general acute care hospital of the candidate’s choice may be used for such observation. Candidates
must make an appointment for such visitation by contacting the Director or a manager of Respiratory
Care at the hospital selected. Alternatively, during the academic year, an observation experience may
be arranged through Program faculty by contacting Patricia Goodwin, RRT, at (516) 572-9640, Ext. 2-
6585.
Document the visit using this form and obtain the signature of the supervising therapist or NCC Clinical
Instructor.
Candidate/Applicant Name:
Date of Observation Experience:
Location of Observation Experience:
Nassau University Medical Center
Long Island Jewish Medical Center
Southside Hospital
Plainview Hospital
Franklin Hospital
Huntington Hospital
Good Samaritan Hospital Medical Center
Glen Cove Hospital
St. Catherine of Siena Medical Center
South Nassau Communities Hospital
Gurwin Jewish Nursing & Rehabilitation Center
St. Francis Hospital - The Heart Center
Winthrop University Hospital
Other (Insert full name of facility):
TO THE RESPIRATORY THERAPIST CONDUCTING THE OBSERVATION EXPERIENCE: Please address and confirm the
applicant’s completion of the elements listed below: check the corresponding boxes and provide your identifying
information. Thank you for your cooperation and assistance.
1. The typical duties and responsibilities and the day-to day practice of a respiratory therapist, in both
critical and non-critical care settings, were reviewed and discussed in detail with the candidate.
2. The candidate was exposed to, and directly observed, patient interaction and/or direct patient care by
respiratory therapist(s) in both:
an acute care, ICU setting
a non-acute care setting
Comments (optional):
Printed Name of Respiratory Therapist
Conducting the Observation Experience:
click to sign
signature
click to edit
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