Fillable SHADOWING / OBSERVATION DOCUMENTATION FORM SOUTHWEST VIRGINIA COMMUNITY (Southwest Virginia Community College)

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SHADOWING / OBSERVATION DOCUMENTATION FORM SOUTHWEST VIRGINIA COMMUNITY (Southwest Virginia Community College)

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U.S.A. forms for Southwest Virginia Community College

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SOUTHWEST VIRGINIA COMMUNITY COLLEGE, VIRGINIA HIGHLANDS COMMUNITY COLLEGE,
COOPERATIVE RADIOLOGIC TECHNOLOGY PROGRAM
SHADOWING / OBSERVATION DOCUMENTATION FORM
Please circle the campus to which the student will be applying: SWCC VHCC
Student (Printed) Name: ______________________________________ EMPLID: ___________________
The signature(s) verify the student above has visited the Diagnostic Imaging Department of the listed facility, and confirm that the hours were
performed as documented.
Students are to submit this completed form to their respective campus, attn. Radiography Applicant, before January 15. Students should keep a
copy for their records and bring with them to the mandatory information session held mid/late-spring semester.
Date
Facility/Hospital
Time
begin
Time
end
Length of
Shadowing
(in hour or 30
minute
increments)
Printed name
of technologist or clinical
instructor
Signature
of technologist or clinical
instructor
TOTAL SHADOWING/OBSERVATION HOURS: ____________________________________
Student: Please discuss your experience(s). List some exams which you witnessed: ____________________________
*This writing section is optional and is neither graded nor counted toward program admission.*
By signing this form, the student is certifying that these documented hours are accurate.
Student Signature: ____________________________________________________ Date: ______________________
Created 3/29/13
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SHADOWING OBSERVATION DOCUMENTATION FORM SOUTHWEST VIRGINIA COMMUNITY (Southwest Virginia Community College)

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Completed 8 October 2020

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