Student Name:
Email:
Center (select one)
Start Date (mm/dd/yy)
End Date (mm/dd/yy)
Total Hours
Site Name
Site Address
Site City
State
Site Zip Code
Shadowing Site Type
If Other, please specify
Primary Preceptor Name
Primary Preceptor Discipline (Select One)
Preceptor Specialty (if applicable)
Preceptor Ethnicity (if known)
Preceptor has copy of mentor evaluation to submit to AHEC
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 would you change about the experience?
Overall, I would rate my preceptor:
Overall, I would rate my experience:
Additional Comments:
