Additional Shadowing Documentation Application

Dear Student,

We at the Northeast Kentucky Area Health Education Center are very excited to assist you in your shadowing experiences and on your path to become a health professional.

Please use this form to submit any documents you may have missed submitting in your original job shadowing application. Please keep in mind in order to qualify for job shadowing opportunities with the Northeast AHEC, you will need to complete the Job Shadowing Application and submit a copy of your immunization records (which includes 2 MMR’s and a flu vaccine if shadowing between October 1 through March 31). You will also need to submit the results of a Quanti-FERON Gold TB Blood Draw Result or a current (within the last year) Two-Step TB Skin Test result. COVID-19 vaccination uploads are now optional- please only upload COVID-19 vaccination proof if you have had any of the vaccinations after September 1, 2023.

If you have any questions or concerns about shadowing you may contact me any time! We hope you enjoy your time shadowing with the Northeast AHEC and look forward to accommodating you throughout your journey of becoming a health professional.

Sincerely,

Lakyn Newcomb

Health Careers Coordinator
Northeast AHEC
St. Claire HealthCare

Email: lakyn.newcomb@st-claire.org

Office phone: 606.783.6787

Hannah Little
Health Careers Coordinator
Northeast AHEC
St. Claire HealthCare
Email: hannah.little@st-claire.org
Office phone: 606.783.6786

Fax number: 606.784.2767

Mailing address: 316 W. 2nd St.

Suite 203

Morehead, KY 40351

Thank you for your interest in job shadowing in the Northeast Kentucky AHEC service region. Please complete this form to the best of your knowledge using only your personal health records and personal information.

Please note that this application requires a signature to be complete. Applications are considered incomplete without appropriate signatures throughout the below documents.
I. GENERAL INFORMATION
First Name:*
MI*
Last Name:*
Email Address:*
Date of Birth:*

MonthDayYear
Last 4 Digits of Social Security #*
EDUCATION:
School/College:*

III. JOB SHADOWING AGREEMENT
Attestation

I attest that I am uploading health records only of which are my own. I understand that I am responsible for submitting the content in this document in its entirety. By signing below, I acknowledge I have read, understand, and agree with all information in this attestation. I understand that I can be dimissed from shadowing should it be determined that I did not follow the guidelines of this attestation or the guidelines and policies/procedures of the facility of which I shadow.
Participant Name*

First NameLast Name
MonthDayYear
Date
Participant Signature*
VI. ADDITIONAL REQUIRED DOCUMENTS

Please use this section to upload your additional documentation.
Attach immunization records here:

Select File

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Attach TB skin test #1 OR Quanti-FERON Gold Blood Draw results here:

Select File
***NOTE: If you elected to do the 2-step TB tests you must submit the results for both TB reads completed within the 7 to 21 day appropriate timeframe. Thank you.*** Cancelof
Attach TB skin test #2 results here:

Select Files

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COVID-19 vaccination upload (optional). Please only upload COVID-19 vaccination proof if you have had any of the vaccinations after September 1, 2023.

Select Files

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Attach flu shot vaccination record here (only required if shadowing October - March):

Select File

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Should be Empty: