Together, we are required to complete documentation on your shadowing experience containing the name, address and dates of contact with the student, the healthcare facility in which the student was placed and evaluations completed by both the student and healthcare facility. Please complete the fields below OR submit a hard copy of your shadowing experience. The mentor evaluation must be provided to your preceptor.

Student Name:

Email:

Start Date:

End Date:

Total Hours:

Site Name:

Site Address:

Site City:

Site State: * -- Select an option -- Please select a State AA - Armed Forces AE - Armed Forces AK - Alaska AL - Alabama AP - Armed Forces AR - Arkansas AZ - Arizona CA - California CO - Colorado CT - Connecticut DC - District of Columbia DE - Delaware FL - Florida GA - Georgia HI - Hawaii IA - Iowa ID - Idaho IL - Illinois IN - Indiana KS - Kansas KY - Kentucky LA - Louisiana MA - Massachusetts MD - Maryland ME - Maine MI - Michigan MN - Minnesota MO - Missouri MS - Mississippi MT - Montana NC - North Carolina ND - North Dakota NE - Nebraska NH - New Hampshire NJ - New Jersey NM - New Mexico NV - Nevada NY - New York OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming

Site Zip Code:

Site Phone:

Shadowing Site Type: -- Select an option -- Hospital Clinic Office Other

If other, please specify:

Primary Preceptor Name:

Primary Preceptor Discipline (Select One):

Allied Health - Assistant/Rehab/Tech/Nutrition/etc.

Medicine - DO/MD

Physician Assistant

Dental - D.D.S

Dental Hygienist

Dental Assistant

Nurse Advanced Practice - CRNA/Nurse Midwives/NP/etc.

Nurse - RN/BSN

Nurse - LPN

Certified Nursing Assistant

Clinical Psych

Pharmacy

Physical Therapy

Physical Therapy Assistant

Occupational

Occupational Therapy Assistant

Public Health

Social Work

Preventative Medicine

Health Care Administrator

EMS/EMT

Paramedic

Respiratory Therapy

Other

If other, please specify:

Preceptor Specialty (if applicable): -- Select an option -- General Medicine Family Medicine Internal Medicine Pediatrics Dentist Dental Hygienist Nurse Practitioner Anesthesiology OB/GYN Emergency Medicine Mental Health

Preceptor Ethnicity (if known): -- Select an option -- American Indian/Alaskan Native Asian Black/African American Hispanic/Latino Hawaiian Pacific Islander White/Caucasian Multi-Racial Other Emergency Medicine Mental Health

If other, please specify:

Preceptor has copy of mentor evaluation to submit to AHEC?

Yes

No

Unknown

What did you observe? List at least 3 things.

What information or skills did you learn about this profession that you didn’t already know?

How will you use the information that you learned from this experience?

What did you learn about yourself during this opportunity?

How did this experience reinforce or change your point of view of this profession?

Did you see or experience anything you cannot see yourself doing as a health professional? Explain.

Has this shadowing experience influenced your health career choice? If so, how?

What did you enjoy about the experience?

What experience during your shadowing day had the most profound impact on you and why?

What would you change about the experience?

Overall, I would rate my experience (select one):

Good - 1

2

3

4

Poor - 5

Overall, I would rate my provider:

Good - 1

2

3

4

Poor - 5

Additional comments:

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