Please complete this application form if you are interested in shadowing a medical professional within CHI St. Joseph Health in Bryan Texas. Once you complete the form, click the submit button at the bottom of the page.

Requirements to Observe

1. Be in good health

2. Pass background screening if observing for more than 1 day

3. Complete TB testing (required prior to start date).

4. Complete Influenza vaccination (required if you are shadowing between October 1st and March 31st yearly)

Name and address

First name:

Last name:

Title:

Street 1:

Street 2:

City:

State:

Zip:

Home phone:

OK to call me here

Work phone:

OK to call me here

Email address:

Demographic Information

You may optionally provide the following information. It is used only to help us get a better idea of the demographic make-up of our volunteers.

Date of birth:

(year optional)

Gender:

Shirt size for uniform:

Availability

Please indicate the date or dates that you would like to shadow.

Sun

Mon

Tue

Wed

Thu

Fri

Sat

From:

To:

Time-frame

Please list the time-frame you wish to shadow for (i.e. Oct. 3rd-Oct. 31st)

Email Address

Our primary mode of communication with you will be through email.

Department You Wish to Observe In

Please list the department(s) you wish to shadow in (if known).

Name of Medical Professional You Will Observe

Please list the name(s) of CHI St. Joseph Health Care worker you wish to shadow. If not known write "unknown."

Reason For Observation Hours?