Shadowing Form
ARKANSAS STATE UNIVERSITY
COLLEGE OF NURSING AND HEALTH PROFESSIONS
Radiologic Sciences Program Shadowing Form - Confidential
Name_____________________________________________ A-State Student ID Number____________________________
This student completed a shadowing experience in the Radiology Department at _____________________________ on __________________.
(Facility Name) (Date)
(Facility Name) (Date)
Please provide a rating (with poor = 0 and excellent = 5) based on your perception of this student’s success in the field of medical imaging and radiation sciences. The rating should encompass interpersonal skills, dependability (i.e. was the student on time and in the correct location), as well as engagement and interest during the shadowing experience.
0 1 2 3 4 5
Why did you provide the above score?
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Please fax Shadowing Form to (870) 972-3485 or email to mirs@astate.edu.
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Technologist Signature/Position Date
_____________________________________ _______________
Email Address Telephone Number