AHEC Form - Student Shadowing Experience

Student Name: *

Email: *

Start Date: *

End Date: *

Total Hours: *

Site Name: *

Site Address: *

Site City: *

Site State: *

Site Zip Code: *

Site Phone: *

Shadowing Site Type: *

If other, please specify:

Primary Preceptor Name: *

If other, please specify:

Preceptor Specialty (if applicable):

Preceptor Ethnicity (if known):

If other, please specify:

Preceptor has copy of mentor evaluation to submit to AHEC? *
Yes No Unknown

What did you observe? List at least 3 things. *

What information or skills did you learn about this profession that you didn’t already know? *

How will you use the information that you learned from this experience? *

What did you learn about yourself during this opportunity? *

How did this experience reinforce or change your point of view of this profession? *

Did you see or experience anything you cannot see yourself doing as a health professional? Explain. *

Has this shadowing experience influenced your health career choice? If so, how? *

What did you enjoy about the experience? *

What experience during your shadowing day had the most profound impact on you and why? *

What would you change about the experience? *

Overall, I would rate my experience (select one): *
Good - 1 2 3 4 Poor - 5

Overall, I would rate my provider: *
Good - 1 2 3 4 Poor - 5

Additional comments: