# Shadowing Form

### **ARKANSAS STATE UNIVERSITY**  
**COLLEGE OF NURSING AND HEALTH PROFESSIONS**

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***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.):