West Central Missouri Area Health Education Center

Connecting Students to Careers,
Professionals to Communities, and
Communities to Better Health.

West Central Missouri AHEC (Area Health Education Center)

MAHEC Shadowing Report

MAHEC is required to report general demographic information about participants in the categories below. This data will be confidentially maintained and will be referenced periodically to evaluate the effectiveness of AHEC services and programs. We appreciate your cooperation in the completion of this form. For more information, please contact the West Central Missouri AHEC office at 816-410-8382 or e-mail lquarles@kclinc.org

Please complete the information below and click Report Now.
* indicates required information

Participant Information
First and Last Names*:
E-mail address*:
Check One:	Ms. Mrs. Mr. Dr.
Last 4 digits of SS#*:
Date of Birth (MM/DD/YY)*:
Gender*:	Male Female
Ethicity*:	American Indian/Alaska Native Asian Black/African American Hispanic/Latino Native Hawaiian/Other Pacific Islander White/Caucasian Multi-Racial
Street*:
City*:
State*:
Zip Code*:
Area Code and Telephone:
Area Code and Cell or Beeper:
Education
Name of your current or last school attended*:
Graduation Date (MM/YY)*:
Degree Obtained (Diploma, BSN, MD, etc.):
Participant Survey
Check all that apply to shadowing participant:	NHSC Recipient Member NHSC Loan Repayment PRIMO Loan First in family to complete college English was a second language growing up Qualified for free or reduced fee school lunch Received Financial Aid Type of financial aid:
Do you plan to practice in-state upon program completion/graduation?	Yes No
Do you plan to practice in a rural setting upon program completion/graduation?	Yes No
Shadowing Information
Start Date (MM/DD/YY)*:
End Date (MM/DD/YY)*:
Total Hours*:
Are you a participant in the ACES or ACES+ program?	ACES ACES+
Shadowing Site Name*:
Shadowing Site Type*:	Hospital Clinic Office Other (explain):
Site Street Address:
Site City*:
Site State*:
Site Zip Code:
Site Area Code and Telephone:
Primary Preceptor's First and Last Names*:
Preceptor's Gender*	Male Female
Preceptor's Ethicity:	American Indian/Alaska Native Asian Black/African American Hispanic/Latino Native Hawaiian/Other Pacific Islander White/Caucasian Multi-Racial
Preceptor's Discipline:	Allied Health Clinical Psych Dental Public Health Dental (D.D.S.) Medicine (DO, MD) Health Care Administrator Advanced Practice Nurse (CRNA, Nurse Midwives, NP, etc.) Nurse, LPN Nurse, RN Pharmacy PA Public Health Social Work Preventive Medicine Other (explain):
Preceptor's Specialty (if applicable):	Family Medicine General Int Med Gen Ped Podiatry Other (explain):
Click to Complete Report:

Contact Us:

West Central Missouri AHEC
c/o Greater Kansas City LINC
3100 Broadway, Suite 1100
Kansas City, MO 64111

Stephanie Taylor
Executive Director
816-410-8380
816-410-8381 fax
staylor@kclinc.org

Carla Tillmon
Recruitment Coordinator
816-410-8382
816-410-8383 fax
ctillmon@kclinc.org

Shaunna Overfelt
Program Assistant
Youth Health Service Corps Coordinator
816-889-5050 x1254
soverfelt@kclinc.org

Health Education Coordinator
816-889-8500
sriddle@kclinc.org

staff@wcmoahec.org