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Shadowing Form

ARKANSAS STATE UNIVERSITY
COLLEGE OF NURSING AND HEALTH PROFESSIONS


Limited Medical Imaging and Safety Program


**Technologists: Please e-mail form to jmcooper@astate.edu
You may take a picture or scan this form to e-mail to Jessica Cooper, Special Programs Coordinator.
Thank you for supporting A-State Radiology programs and students.

Radiology Shadowing Form

  • Student Name:                                                                               
  • A-State Student ID Number:
  • Facility Name:
  • Shadowing Date:

Student shadowed X-Ray for _____________ hours. Tech shadowed: ______________________________________________

Student shadowed MRI for _____________ hours. Tech shadowed: ________________________________________________

  • Staff Signature/Position:
  • Date:
  • Email Address:
  • Phone Number:
  • Additional Comments (student engagement, professionalism, punctuality, etc.):


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