Shadowing Form

ARKANSAS STATE UNIVERSITY
COLLEGE OF NURSING AND HEALTH PROFESSIONS

Limited Medical Imaging and Safety Program

Radiology Shadowing Form

______________________________________________________________          _____________________________________________________________________
Student Name                                                                                   A-State Student ID Number

_______________________________________________   completed a shadowing experience in the Radiology department at 
(student name)

______________________________________________________ on ____________________________________________.
(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.):

 

 

 

**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 your support ofsupporting 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.):