Applicant Information

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* 1. Applicant Information

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* 2. Date of birth

Date of birth

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* 3. Name of school you are currently attending:

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* 4. Name of employee (mentor) you will be observing:
*If you have any questions on where to report for your learning experience you will contact this person or go to the information help desk*

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* 5. Name of hospital where you will shadow

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* 6. Mentor's telephone number:

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* 7. Unit/Department Name:

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* 8. List the date(s) you are cleared for your learning experience:
**Please note that you are only cleared for 16 total hours and as such may not do more than two 8 hour shifts OR breakdown your experience into smaller shifts over a longer period of time for a total of 16 hours**

Date(s)
Date(s) [If applicable]
Date(s) [If applicable]
Date(s) [If applicable]
Date(s) [If applicable]
Date(s) [If applicable]
Date(s) [If applicable]

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* 9. Number of total hours you will observe: 
**No more than 16 total hours**

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* 10. Start time of Shadow Experience:

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* 11. End time of Shadow Experience:

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* 12. E-mail confirmation

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* 13. Please attach a copy of Tuberculin status (PPD) documented within the last 12 months. (If positive results - must provide copy of radiology report and doctor's letter).

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