Nursing Job Shadow Request

Last Name

First Name

Phone

Email Address

Current School

Program

Please state the overall goal for your experience at Northern Light Eastern Maine Medical Center

Desired Location or Specialty

Employee to shadow (if known)

Shift Length

Length in days

Vaccinations

Please send proof of immunizations. (Those without a history of chickenpox must show proof of immunity by official immunization records (2doses) or a positive serum titer

Sent Hepatitis B Record

Sent TDap Record

Sent MMR Record

Sent Varicella Record

Sent Influenza Record

Current Season

TB Test

2-Step PPD or Tspot Accepted

Vaccines

PDF. JPEG. PNG Only Accepted

Drop your files here

Attestation

By typing your name in the box below this will represent your digital signature verifying that you have submitted proof of all required vaccinations

Required Paperwork

Click Here

Check this box that you have read and understand the following documents within the link provided above

Signature

By typing your name in the box below this will represent your digital signature verifying that you read and understand the attached documents

Date Completed

Send me a copy of my responses

Report Abuse