Omaha AHEC Pharmacy Shadowing Application Form

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Thank you for your interest in shadowing with the Omaha AHEC.

This shadowing opportunity is offered in partnership with local Walgreens pharmacies.

Please complete this application form to be considered for a shadowing opportunity.

Should you be selected for this opportunity, some of the information on this form will be shared with the pharmacy, including your name and contact information.

If you have questions, please reach out to Clare Maakestad, Omaha AHEC Coordinator at cmaakestad@unomaha.edu.

Application Information

First Name

Last Name

Email Address

Phone Number

In 2-3 sentences, explain why you are interested in this shadowing opportunity.

Upload your resume.

Upload a copy of your unofficial transcript.

Have you already earned your HIPAA Certificate through the Omaha AHEC?

YesNoUnsureThe Omaha AHEC HIPAA Certificate is offered to students who pass the HIPAA Quiz in UNO BIOL 1060.

Shadowing opportunities are offered in 4- and 8-hour shifts on the last Friday of each month. Please indicate which schedule you prefer:

9:30 am - 1:30 pm (4 hours)2:00 pm - 6:00 pm (4 hours) 9:30 am - 5:30 pm (8 hours)Note: You must plan to arrive at least 10 minutes early to your scheduled shadowing time.

Emergency Contact

Please list your emergency contact who would be available in case of emergency during your shadowing experience.

Emergency Contact Name

Emergency Contact Relationship to You

Emergency Contact Phone Number

Omaha AHEC Pharmacy Shadowing Application Form

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PLEASE PROCEED TO THE NEXT PAGE TO TAKE A QUIZ.

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Please read the Omaha AHEC: Shadowing Guide PDF.

Then take this brief quiz: