Job Shadow Verification Form
Name:________________________________________________________
(Please Print)
Email:________________________________________________________
San Juan College Student ID#:_____________________________________
Please read the statement below and then sign and date this form.
As a San Juan College Student in the Respiratory Therapy Program, I understand
I am required to job shadow prior to the start of the academic year.
Student Signature: ______________________________________________
Date: _________________________________________________________
Name of Hospital: ______________________________________________________________
Date Job Shadow Completed: _____________________________________________________
Name of Respiratory Therapist (printed): ____________________________________________
Signature of Respiratory Therapist: _________________________________________________
Comments:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
If you have any questions concerning this form, you may call (505) 566-3851 or email
[email protected]
Student must return this form to the Respiratory Program Administrative Assistant to be put in
file directly following completion of job shadowing.