Connecting Students to Careers, Professionals to Communities, & Communities to Better Health. Annual Report HOME ABOUT PROGRAMS RESOURCES CALENDAR NEWS CONTACT Shadow Experience Information Form Student Name * High School/College * Street Address * City * State * Zip * Date of Birth: Grade: High School FreshmanHigh School SophomoreHigh School JuniorHigh School SeniorCollege FreshmanCollege SophomoreCollege JuniorCollege SeniorCollege Graduate Student Home Phone Number * Mobile Phone Number * Email Address * Gender: * MaleFemale Ethnicity: Hispanic * YesNo Race: * CaucasianAfrican AmericanNative AmericanPacific IslanderAsianOther Please List your primary areas of interest: Interest 1: Interest 2: Interest 3: Interest 4: Do you have a health care professional(s) in mind who you would like to shadow? What do you hope to learn in you experience? * Dates you wish to shadow: (Please note we cannot guarantee your dates) Date 1: Date 2: Date 3: Number of shadowing hours desired: * Shadow Experience Authorization and Release of Liability Acknowledgement of Student (19 years or older): I understand and agree to maintain patient confidentiality and adhere to the established dress standards that have been identified. I recognize that I may be exposed to potential risks as a result of this experience and agree not to hold the shadow experience provider or Nebraska Panhandle Area Health Education Center liable for any injury as the result of this experience. Student's Signature: Date: Permission of Parent (Student under 19 years of age) I grant my child, who is 16 years of age or older, permission to participate in the approved shadow experience. I understand that he/she may be exposed to patient information and that we are responsible for keeping it confidential and to adhere to the established dress standards that have been identified. I also recognize that he/she may be exposed to potential risks as a result of this experience and agree not to hold the job shadow experience provider or Nebraska Panhandle Area Health Education Center liable for any harm or injury as a result of this experience. Parent's Signature: Date: Rules for Shadow Experience Time is valuable for everyone involved. If you are unsure of a date or waiting for a new work schedule, it is better to leave the dates blank when completing the Shadow Experience Information Form and include a note stating that an e-mail or phone call will follow with definite dates. When considering shadowing dates, check the school calendar for activities, class schedules, possible test dates, and medical appointments. When shadowing at a hospital, there are at least three to four people involved in the shadowing process, so if a shadowing experience has to be rescheduled it is not an easy process to change the date. The number one complaint from the preceptors or shadowing site is the dress code. You leave a first impression with the shadowing site by the way you dress. You must dress in a manner that presents professionalism. No blue jeans, sleeveless blouses or shirts, extreme hairstyles or jewelry, short skirts or dresses, shorts, sandals or open-toed shoes. Tattoos and undergarments must be covered at all times. You need to arrive on time and be polite, courteous, and enthusiastic. If the site is unfamiliar to you, do a trial run to the site. If you are going to be late, please call in to the site. Always remember to ask questions. Shadowing sites are taking time from their busy day to share with the student their profession. Not asking questions can be viewed as the student is not interested in their field. We understand that many times the health professional has answered all your questions and you are overwhelmed, but it is important that you ask a couple of questions. For example, "What do you enjoy most about your profession?" or "If you could have chosen another health profession what would it be?" Some sites may need the student to sign additional forms specific to their site. You may be asked to change into scrubs or a lab coat. There may be other restrictions. No cell phones or bracelets are allowed, so be prepared. Some sites require flu shots. When scheduling a shadowing day, the appointment calendar is usually taken into consideration so you are not shadowing on a slow day. A few patients may cancel at the last minute or prefer not to have you in the room. Also, the patient count in that particular hospital department may have taken a downward swing since the scheduling date and shadowing day. One of the staff members may be out of the office unexpectedly on your shadowing day, causing other staff members to be overwhelmed with the increased workload. Be flexible and know that last minute changes do occur frequently. While shadowing if the staff seems to be overwhelmed with emergencies, or patients have cancelled and there is not anything to do, ask the staff at the site if it would be better to shadow another time by negotiating an agreeable time. I understand and agree to abide by the Nebraska Panhandle Area Health Education Center Rules for Shadow Experience and any additional site specific Rules for Shadow Experience. Student's Signature: * Date: Parent's Signature: (If under 19 years of age) Date: © A non-profit Area Health Education Center (AHEC) operating in partnership with the University of Nebraska Medical Center, Nebraska AHEC Program Office.