Shadowing Log | NEAHEC

Observation/Shadowing Log

Any person who has observed/shadowed a healthcare provider in NE KY AHEC's 17 county service region (Bath, Boyd, Carter, Clark, Elliott, Fleming, Greenup, Lawrence, Lewis, Mason, Menifee, Montgomery, Morgan, Nicholas, Powell, Robertson, and Rowan.) Students must complete this log at the end of their experience. A maximum of 40 hours per year are permitted.
Name *

First Name Middle Name Last Name
E-mail *
example@example.com
Phone Number *

Area Code Phone Number
Facility: *
i.e. St.Claire Healthcare, Clark Regional Medical Center, King's Daughter's Medical Center, etc.
Department: *
i.e. radiology, oncology, family medicine, emergency, etc.
Preceptor Shadowed: *
i.e. A doctor, nurse, physician assistant, therapist, etc.
Date of observation: *

Month Day Year
Date
Start time of observation: *

: Hour Minutes AM/PM Option
End time of observation: *

: Hour Minutes AM/PM Option
Total number of hours shadowed/observed: *
*Only 40 hours are permitted per year.*
When I would like to shadow again:

Month Day Year
Date Hour Minutes AM/PM Option
Should be Empty:

Observation/Shadowing Log