Fillable Pa Shadowing Form - Baldwin Wallace University printable pdf download

Pa Shadowing Form - Baldwin Wallace University

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BALDWIN WALLACE UNIVERSITY

Physician Assistant Program – Master of Medical Science (MMS)

PA Shadowing Form

To be completed by the Applicant:

This section of form only is a fillable PDF. Options for completing: print and complete by hand or

print after typing Applicant section; provide to the Physician Assistant for completing bottom section.

Applicant Last Name _____________________________ First Name___________________

Phone

Email ___________________________________

Physician Assistant Name

PA Employer ____________________________________Type of Practice_______________

Street Address __________________________________________________________________

City, State, Zip Code ___________________________________________________________________

Shadowing Date(s) ______________________________________________________________

Total Number of Hours

_____

Describe your shadowing experience, types of patients seen, and the duties of the PA:

To be completed by the Physician Assistant:

I verify that

shadowed me as indicated above.

_____________________________________________

(Name of Applicant)

PA-C

Signature

Date_______________

PA-C

Name (printed)

NCCPA ID __________________________________________

Please check if interested (Ohio location only):

Yes, I am interested in being a preceptor for a BW PA student; contact me by

Phone: _____________________________ or Email: __________________________________.

Send this form to: Admission Office, Baldwin Wallace University, 275 Eastland Road, Berea OH 44017

Fax 440-826-3830

paprogram@bw.edu

Pa Shadowing Form - Baldwin Wallace University

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