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BVRMC Job Shadow
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1.
Name (first and last)
(Required.)
*
2.
Email Address
(Required.)
*
3.
Phone number
(Required.)
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4.
Which school do you currently attend?
(Required.)
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5.
Which hospital department(s) are you interested in job shadowing? (
Select all that apply)
(Required.)
Nursing- Medical/Surgical
Nursing- Emergency Room
Nursing- Operating Room
Nursing- Same Day Surgery/Endoscopy
Nursing- Obstetrics
Physical/Occupational Therapy
Radiology
Laboratory
Pharmacy
Fitness & Health Center
Respiratory Therapy
Office Professional
Interpreter Services
Other (please specify)
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6.
Which day(s) work best for you?
(Select all that apply)
(Required.)
Monday
Tuesday
Wednesday
Thursday
Friday
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7.
What time of day works best for your shadowing shift?
(Select all that apply)
(Required.)
Morning
Afternoon
Other (specific times/timeframe that work)
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8.
How long would you like your shadowing shift to be?
For example: One hour, 2 hours, 3 hours.
(Required.)
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9.
Is there anything else you would like us to know?
(Any special accommodations, goals, preferences or requirements that need met?)
(Required.)
*
10.
Please read the
HIPAA Privacy and Security Document
and provide acknowledgement that you read it. I have read and understand the HIPAA Privacy and Security Document.
(Required.)
Yes
No