Shadowing Application
Demographic
First name
Last name
Address
City
State
Zip
Contact number
Alternate Contact number
Email address
Date of Birth
Do you have someone who has agreed to allow you to shadow them?
Yes
No
Job Role Information
Job role you are requesting to shadow
Name of preceptor
Email of preceptor
Requested date(s) for Job Shadowing experience
You will need to find and secure your own preceptor host for shadowing. Please list below your desired shadowing experience.
The Office of Learner Affairs cannot guarantee placement with a preceptor.
Applicant Information
Name of School/College/University
Grade (Freshman, Sophomore, Junior, or Senior)
Have you applied or already been accepted into a college or university healthcare related program? If yes, please explain.
Is this a class or program requirement?
Yes
No
Please explain requirement. Example: I need to shadow 20 hours before I can be accepted into my major.
Name of School or Program
School contact name
School contact email address
School phone number
What do you hope to gain from a shadowing experience at Charleston Area Medical Center/Vandalia Health?
Have you ever been convicted or pled guilty to a violation, even if dismissed, of any law other than a minor traffic violation?
Yes
No
If yes, list the violation and date of conviction or plea:
Health Screening Questionnaire
Have you traveled anywhere within the last 8 weeks? If so, where:
List any chronic health problems or immune disorders:
List any allergies:
Describe any chronic skin conditions or open wounds:
Have you ever had any exposure with active tuberculosis?
Yes
No
Have you had a positive TB skin test?
Yes
No
Current PPD date. (must be current within 1 year). Please submit result of PPD. ***must provide results from a physician's office***
Have you ever had chicken pox? ***must provide proof of immunity, tier, or 2 vaccinations***
Yes
No
Immunizations
All immunizations are required before approval of application. Please list immunizations for the following diseases and attached a copy of immunization records.
Measles, Mumps, Rubella (MMR)
Date Received
Date Received (Must list 2 dates)
Varivax (Chicken Pox)
Date Received
Hepatitis B
Date Received
Date Received
Polio
Date Received
Adult tDap
Date Received
Date Received
Seasonal Flu Vaccine
Date Received (required if shadowing between October through April)
Learners should avoid being in patient care areas if they have relevant contagious respiratory, gastrointestinal, or skin diseases.
By typing your name and date below, you certify that the forgoing statements are true and complete.
In addition, if applicant is < 18 years of age, please include parental or legal guardian name and phone number below.
Please upload a copy of your immunization records:
Marketing
There may be instances of photographs taken at Conferences/Educational events. I give my permission for photographs to be taken of me to be used in publications, television, websites or other visual media as related to the learning experience and all collaborating agencies. I understand that the above videotapes/photographs become the property of CAMC Health Systems. The videotapes/photographs may be used for news, education or other purposes related to the promotion of workforce development at CAMC Health Systems.
Yes
No- Please contact OLA@vandaliahealth.org
Required Education
Click the radial to confirm you are aware of the required education that must be completed prior to starting. The education information and link will appear on the next screen.
Yes I am aware of the education requirement.
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