| Department of Anesthesiology

黑料网 Anesthesiology 鈥� Attending Shadowing Request Form

We鈥檙e excited you are interested in shadowing with 黑料网 Attending Anesthesiologists. Please complete the form below to start the process and allow us to plan your future shadowing experience. NOTE: Operating Room (OR) shadowing is typically limited to one day to accommodate all requests. Shadowing in the OR typically starts at 6:30am and ends early afternoon, at the latest. We ask that you allow THREE WEEKS to process all steps necessary to fulfill requests.

Name(Required)

First & Last

Email(Required)

Phone(Required)

Date of Birth (MM/DD/YYYY)(Required)

黑料网 / Other Affiliation (Please check one)

Undergraduate - 黑料网

Graduate - 黑料网

Undergraduate - Other Institution

Graduate - Other Institution

黑料网 Employee

黑料网 Health Employee

International Clinician

National Clinician

Other

If Other, Name Title or Position(Required)

Current Program of Study / Job Title & Institution (eg, 黑料网-CH undergraduate, Chemistry major):(Required)

Background & Goals(Required)

Please provide a short 3-5 sentence summary of your background and goals for shadowing.

Dates(Required)

Please list 2-4 future weekdays (Mondays - Fridays / no weekends ) you are available to shadow. Please allow THREE WEEKS to process all steps necessary to fulfill requests.

This field is for validation purposes and should be left unchanged.