Student Shadowing Experience

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:

Start Date (MM/DD/YYYY):

End Date (MM/DD/YYYY):

Total Hours:

Site Name:

Site Address:

Site City:

Site State:

Site Zipcode:

Site Phone:

Shadowing Site Type:

If other, please specify:

Primary Preceptor Name:

Primary Preceptor Discipline (Select One):

If other, please specify:

Preceptor Specialty (if applicable):

Preceptor Ethnicity (if known):

If other, please specify:

Preceptor has copy of mentor evaluation to submit to AHEC?

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):

Overall, I would rate my provider:

Additional comments: