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) 

 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? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ________________________________________________________________________________________________________ 

 Please fax Shadowing Form to (870) 972-3485 or email to mirs@astate.edu . 

 ________________________________________                   ___________________ Technologist Signature/Position                                               Date 

 _____________________________________                         _______________ Email Address                                                                       Telephone Number