Preceptor & Site Profile Form 2018-2019

To avoid scheduling errors, please contact the program as soon as possible if any changes in hospital affiliation, practice location, etc. occur after this form has been submitted.

1.  Allied Health Providers (PA’s, NP’s, LPC, MSW, etc.) *PHYSICIANS PROCEED TO SECTION 2*

Name and Credentials
Are you Board Certified? / ☐ yes ☐No ☐board eligible
National Certifying Board
Date certified/re-certified (Mo/Yr)
Practice Specialty
Medical License / Number: / State: / Expiration Date:
Email address
Preferred contact phone (for program use only) / ☐cell ☐office ☐pager ☐home
Phone no. students may use to contact you. / ☐cell ☐office ☐pager ☐home
Do you precept students from other programs? / ☐Yes ☐No List programs:
Name of your primary supervising physician.
Please also complete physician information below

2.  Physician

Name and Credentials
Are you Board Certified? / ☐Yes ☐No ☐Board Eligible
Area of Board Certification
Date certified/re-certified (Mo/Yr)
Practice Specialty
Medical License / Number: / State: / Expiration Date:
Email address
Preferred contact phone (for program use only) / ☐cell ☐office ☐pager ☐home
Phone no. students may use to contact you / ☐cell ☐office ☐pager ☐home
Do you precept students from other programs? / ☐Yes ☐No List programs:

Practice Contact Information

Practice/Group Name:
(Contract Entity Name)
Please Attach Certificate of Insurance, if available
Employer Name (if different from above): / ☐ Self-Employed ☐Employed by
Main Office Address:
Rotation Address
(If different from above)
Contact Person/Office Manager
*For rotation scheduling / Name:
Phone:
Fax: / Email:

Practice Information

What hours will the student be seeing patients in your office?

/

☐ M ☐ Tu ☐ W ☐ Th ☐ Fri

Weekends: ☐Yes ☐No

What hours will the student spend seeing inpatients?

/

☐ M ☐ Tu ☐ W ☐ Th ☐ Fri

Weekends: ☐Yes ☐No

How many outpatients do you see daily? / How many inpatients do you see daily? / # of hrs/week student will train with you (36 min)
Hands on experience is an important component of student learning; Please circle the activities that students may be allowed to observe/perform, with supervision, during their time with you:
☐History Taking ☐ Assist with surgical procedures ☐ Documentation
☐ Physical Examination ☐ Perform patient call-backs ☐ Rounds
☐ Lab interpretation ☐ Imaging Interpretation ☐ In-office procedures
Other, please list

Scheduling Information

/
Please indicate the TOTAL NUMBER of students you would like to train during EACH rotation block below:
2018-2019 Rotation Block Schedule
Rotation Number / Start Date / End Date / Total Number of Students for this block
Rotation 1 / 7/9/18 / 8/16/18
Rotation 2 / 8/20/18 / 9/25/18
Rotation 3 / 10/1/18 / 11/1/18
Rotation 4 / 11/5/18 / 12/13/18
Rotation 5 / 1/7/19 / 2/14/19
Rotation 6 / 2/18/19 / 3/26/19
Rotation 7 / 4/1/19 / 5/9/19
BREAK
Rotation 8 / 5/28/19 / 6/27/19
Rotation 9 / 7/8/19 / 8/8/19
☐ / I am unsure of my availability for 2017-2018; please contact me on an ‘as-needed’ basis for student placement (please check box).
☐ / I am interested in precepting additional students (please check box and indicate the rotations and number of students).
Is there a SPECIFIC STUDENT for whom you are providing this availability? If so, please provide his/her name below:

Hospital Affiliations

To avoid scheduling errors, please contact the program as soon as possible if any changes in hospital affiliation, practice location, etc. occur after this form has been submitted.

Do you see or treat patients in a hospital or free-standing surgical center? / ☐YES ☐NO
Please note: Accurate hospital/surgicenter information is critical for student credentialing and University/hospital affiliation agreement processing. Students will only be credentialed at a maximum of four hospital sites. Please list the four sites you attend most often.
Facility Name
and address / Hospital System Name / Are you an employee of this facility? / #days/wk you attend this facility / Name/ph # of hospital education coordinator / Do students need EMR access for this facility? (Y/N)
eg. Tempe St. Luke’s Hospital
1500 S. Mill Ave, Tempe, AZ / Iasis Healthcare / No / 2 / Mary Smith, Med Staff Svcs 555-5555
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Additional Comments

Thank you so much for providing this opportunity for our students. The Clinical Year faculty are here to support your educational efforts; please contact us any time with questions or concerns. Ph (623) 572-3680

Please email this form to: or please fax form to: (623) 572-3227

For Program Use Only

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