Download Medical Radiography (MRAD) Applicant Hospital/Imaging Clinic Job Shadow Form

Medical Radiography (MRAD) Applicant
Hospital/Imaging Clinic Job Shadow Form
Contact the Imaging Department at any clinic and/or hospital to sign up for job shadowing. Complete the 16
hours of job shadowing. Many sites require different things in order for you to start job shadowing.
Example: filling out an application to job shadow, going to an orientation, drug screen, etc. Each site will be
different, so be prepared for a variety of options. The goal is that you are in the Imaging Area and experiencing
patients and exams performed during a routine day. Another way to put this is you would be seeing first-hand
what goes on in the Imaging Area on a day-to-day basis. Again, you are not replacing the staff in the
department. You are there to see the practical side of the field so you will know you made the correct career
choice. Note: for students accepted into the program the completed hours and form must be submitted by
December 1st prior to the first quarter of the program.
I understand that all patient observations and information regarding anything I see, hear, or witness are strictly
confidential. I have reviewed the HIPAA policies and dress code in effect at this site and realize that I am job
shadowing and cannot hold Clark College liable. Further, I understand there may be risks involved and I agree to
assume these as part of my job shadowing hours.
MRAD Applicant's Name (print): _________________________________ SID:____________________________
Signature of Applicant _____________________________
Date: _______________________
Name of Hospital/Clinic: _____________________________
Date
Location
Hours
Supervised by
Total # of Hours
A minimum of 16 hours of job shadowing is required. Eight (8) hours must be in a hospital setting.
Clinical Facility Contact Information
Name (print) and Credentials:_____________________________________________________________
Address: _____________________________________________________________________________
Phone Number: _______________________ E-mail Address: ___________________________________
Clinical Facility Contact Signature: _____________________________ Date: _______________________
Revised: 5/5/15