PA & NP Observer Form

Please review and complete the form below, and be aware that there may be a 2 week lead time required for certain observational experiences. Please also be aware that all observers must be at least 16 years or older to complete an observation at Lakeland Health.

* Required Field

First Name*

Last Name*

I understand that I must be at least 16 years or older to participate in an observation at Lakeland Health and I am confirming that I am at least 16 years old.

Yes
No

Email Address*

Phone*

Street Address *

City *

Zip *

School *

Expected Graduation Date

Have you previously participated in Lakeland Health’s Observation Program? If so, when, where, and how many hours?

I understand I can only observe for a maximum of 16hrs, unless I have documentation that states otherwise *

Yes
No

Number of observation hours requested (If you are requesting more than 16 hours please include the reason in the additional comments section below)*

Additional Comments

Please indicate facility preference *

List desired dates for observational experience - 1st preference (Please be as specific as possible in order to better facilitate placement.) *

List desired dates for observational experience - 2nd preference

Please indicate up to three health professions you are interested in shadowing. (Please be as specific as possible with request for departments in order to better facilitate placement.) *

Physician Assistant (List specific department below)
Nurse Practitioner (List specific department below)
Other (specify below)

Please specify which department

If you selected "Other" above please specify which department

Additional Comments

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PA & NP Observer Form

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