Request to Shadow

This form must be completed in full and submitted to the Facility Administrator or Director of Nursing at least two (2) weeks prior to the requested date. All shadowing is subject to facility approval, patient privacy protections under HIPAA (45 C.F.R. Parts 160 and 164), Georgia patient confidentiality statutes (O.C.G.A. § 31-33-1 et seq.), and the operational needs of the facility. Approval is not guaranteed. All approved individuals must comply with facility policies and all applicable state and federal regulations.

Name*

Email*

Phone*

Location

Academic Background

Applicant Type

School / Institution*

GPA or Class Standing

Graduation Year

Preferred Dates & Duration

Preferred Start Date*

Preferred End Date

Preferred Location(s)

‍Lawrenceville‍Athens‍ASC

Goals & Statement — Why do you want to shadow?*

Requirements & Agreement

HIPAA AcknowledgmentI understand I will be required to complete a HIPAA confidentiality agreement before my first day and that all patient information observed during my visit is strictly confidential.*Requirements
AcknowledgmentI confirm I am able to provide proof of immunization records, a current CPR certification, and a valid student or professional ID upon request.*Conduct AgreementI agree to adhere to SSCGA’s dress code, attendance, and professional conduct expectations for the full duration of my shadow experience.*

If Approved Please ensure to bring all files, Identification and neccesary Materials.

Request to Shadow

Request to Shadow

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