LEHIGH CARBON COMMUNITY COLLEGE
MEDICAL ASSISTANT PROGRAM
Observation Hours Verification for Applicants
Applicant to complete this section
Student's Name:
LCCC ID No.: Applying for Admission for the Academic Year:
I hereby give my permission for a member of the LCCC Medical Assistant Admission Committee to contact
this medical department regarding details of my observation. Also, I acknowledge that by law, I am required
to keep all information related to specific patients and their medical treatment strictly confidential.
Student Signature: Date:
Medical personnel who spent time with student should verify the following:
Date(s) Student Observed in Medical Office/Department:
Total # of Hours Student Observed in Medical Office/Department:
Student appeared professional.
Student appeared interested and asked questions.
Did the student observe clerical/administrative duties during observation time? □ Yes □ No
If yes, please list a few tasks observed.
Did the student observe clinical duties during observation time? □ Yes □ No
If yes, please list a few tasks observed.
Comments: (Please write any additional comments you observed or noted while spending time with student
that might be helpful to Admissions Committee.)
OVER
