Fillable Physician Assistant Shadowing V erification (Presbyterian College)

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Physician Assistant Shadowing V erification (Presbyterian College)

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Graduate
Pr
ogram
Physician Assistant Shadowing
V
erification
Instructions
Please complete
this form to verify that you have
participated
in an
experience
with a
practicing physician
or physician assistant.
This
experience
can be in the form of
shadowing, internship, volunteer
or work
experience. Applicants are required to complete a minimum of 250 hours. At least 50 of the 250 hours
must be from direct shadowing of a physician assistant.
Applicant
Infor
mation
Name
First Middle Initial Last
Curr
ent
Addr
ess
City
State
Zip
Shadowing Experience
Institution/Location
Date(s) of
Experience
T
otal
Number
of
Hours
Physician / Physician
Assistant
Infor
mation
Name
W
orkplace
Addr
ess
City
State
Zip
Phone
E-mail
Addr
ess
I
verify that the
above-named applicant participated
in an
opportunity
to
explore
the physician
assistant
profession
by
spending
time
observing
me in
practice.
Physician/Physician Assistant
Signature Date
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Physician Assistant Shadowing V erification (Presbyterian College)

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Completed 23 July 2020

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