Cheshire Medical Center Job Shadow Application

Cheshire Medical Center

Job Shadow Application

Your Name:*

Phone Number

Phone

Email Address*

Will you be age 18 or older at the time of the observation?

Select

Please describe what jobs you are interested in shadowing.

Earliest Observation Date*

What is the earliest day that you would be interested in observing? Please bear in mind that due to staffing schedules, it may take up to 4 weeks to confirm availability.

Latest Observation Date*

What is the latest day that you would be interested in observing?

Scheduling Information

Please suggest between 2 and 5 possible dates and times for observations. For applicants not employed by Cheshire Medical Center or Dartmouth Health, weekdays are preferred.

If you have general scheduling information (such as no availability on Tuesdays), please note this as well.

Total Observation Hours Requested

Most shadowing/observation experiences cover a period of 8 hours or less, and additional documentation may be required for extended observations. If you are interested in an extended observership (more than 5 days) at Cheshire, please consider applying for an observation-only student rotation.

Check here if you are currently a student:

Name of School, University, or other Training Program

Degree Program

The type of degree or diploma you are pursuing (e.g., MSN, Pre-Med, High School, etc.)

Please note and acknowledge the following:

• You will be responsible for tracking your own shadow/observation hours and documenting them as necessary.

• Additional information may be requested prior to the start of your observation experience.

• You will be required to attend an orientation prior to observing. This orientation will include a review of your responsibilities regarding confidentiality, codes of conduct, and the Cheshire Medical Center Standards of Performance

• If you are younger than 18 years of age, parental permission will be requested prior to the start of the observation experience.

Acknowledgement*

I acknowledge that I have read and agree to the stipulations above.

Send me a copy of my responses

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