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.):