CAPA Job Shadowing Program: PA Interest Form

First Name *

Last Name *

Email *

Phone *

City *

License Number *

Please enter your PA license number

Professional Designation *

Enter required value PA-C PA PA-S MD DO FNP FNP-C PharmD Pre-PA

PA Program *

Enter required value A.T. Still University California Baptist University Central Coast Chapman University Charles R. Drew University CSU Monterey Bay Dominican University Keck Graduate Institute Loma Linda University Marshall B. Ketchum University Point Loma Nazarene University Samuel Merritt University Southern California University of Health Sciences Stanford University Touro University – California Touro University - Los Angeles Touro University Nevada University of California-Davis University of California-San Diego University of LaVerne University of Southern California University of the Pacific Western University of Health Sciences Other

If you selected other, please list the program

Graduation Date *

What area of healthcare do you practice in? *

Primary care/General Medicine/Family Medicine

Emergency Medicine

Urgent Care

Internal Medicine and IM Subspecialties (cardiology, endocrinology)

General Surgery

Pediatrics

Orthopedics

Dermatology

Other

If other, please describe

Workplace Information *

Facility Name

Location (City): *

Enter multiple locations, if applicable.

Is your workplace supportive of shadowing opportunities? *

Yes

No, but I would like to get resources to help my practice consider these opportunities.

Do not know, but I would like to get resources to persuade my practice to provide these opportunities.

Maximum number of pre-PA students you will accept

Are there specific requirements or limitations that we should be aware of? *

i.e. facility policies, liability waivers, NDAs, immunization proof, COVID vaccinations, etc.

Availability *

Preferred Days for Shadowing (Check all that apply):

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Your typical work hours/schedule: *

Maximum number of shadowing hours per day *

Enter how many hours per shift/day you may be able to offer

Type of Care Setting (Check all that apply): *

Hospital

Emergency Department

Urgent care clinic

Private Practice

FQHC

Community Health Clinic (CHC)/Nonprofit clinic

Rural Health Clinic

Other

If other, please describe

Why are you interested in participating in the shadowing program?