Shadow Experience Summary/Questionnaire

Please take a few moments to share with us about your shadow experience. What worked well, what did not work very well? Tell us about your mentor. Did you receive valuable information, and how can we improve our process?

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

Shadow:Experience Date *:

Mentor: *

Did you enjoy the experience and did you leam things that you feel will help guide you toward a career decision?
YesNo

If No, please explain:

What particular events/experiences did you most enjoy? *

What particular events/experiences did you least enjoy? *

Did you feel welcome by your mentor during your shadowing experience?
YesNo

Did you feel the person you shadowed had a positive attitude?
YesNo

If No, please explain:

Do you feel like your experience was time well spent?
YesNo

If No, please explain:

Would you consider the job shadow provider for another shadow experience?
YesNo

If No, please explain:

Is there another area of healthcare you would like to shadow?
YesNo

If Yes, what area?

How can we further assist in your healthcare career choice? *

If you were to shadow again, how could we improve the process? *

How did this experience influence your decision to become/or not become a healthcare professional? *