Agriculture, Biology, and Health Sciences - 2800 West Gore Blvd Lawton, OK 73505 (580) 250-5577
Radiologic Technology– Job Shadowing Experience (Observation Only)
Concerning: (please print)
Name ____________________________________________________________________________________________________________
Last First MI
I understand that in this job shadowing experience, my role is that of a student in an observation capacity only. I also understand that I am not expected to provide any patient care, but to
observe and learn the scope of practice of radiologic technologists first hand. Furthermore, this job shadowing experience is a requirement to complete my application into the Radiologic
Technology degree major at Cameron University.
Date: _____________________________________________Signature: ________________________________________________________
RADIOLOGIC TECHNOLOGY APPLICANT: Please observe and evaluate a radiologic technologist in multiple areas of the hospital, such as the radiology department, emergency room, the
intensive care unit, and medical/surgical floor areas.
APPLICANT TRAIT EVALUATION: PLEASE EVALUATE THE APPLICANT ON ACTUAL OBSERVED PERFORMANCE AS COMPARED TO OTHER STUDENTS YOU HAVE KNOWN WITH SIMILAR
BACKGROUNDS.
1. Motivation:
Highly Motivated
Motivated
2. Concern for Others:
Sincerely concerned
Generally concerned
3. Interpersonal Relation:
Relates exceptionally well
Usually relates well
4. Attendance:
Always on time
Usually on time
5. Attendance:
Always neat and clean
Generally neat and clean
The desire to invest him/her self to reach goals.
Inconsistent
Unmotivated
The consideration of other’s feelings.
Occasionally concerned
Indifferent
The ability to develop effective interactions with others.
Displays difficulty in relating to others
Unable to effectively interact with others
The reliability to be at assigned area on time.
Unreliable
Never on time
Appearance is professionally appropriate for the situation.
Frequently sloppy and/or dirty
Never neat and clean
Number of Hours Applicant Observed at your Facility
By signing this form, I affirm that I am a registered radiologic technologist. I also verify the applicant has completed
the designated amount of observation hours while under my supervision.
Date: Printed Name:
Facility Name:
Signature: _______________________________________________________
Return completed form with application to: Cameron University at Great Plains Technology Center, Building 700, Office 710,
4500 SW Lee Blvd, Lawton, OK 73505.
