Preceptor Information Form

Information on the provider who will be precepting.

Name * Required
First Last
Credentials * Required
Practice Specialty * Required
Licensing States * Required
National Certifications * Required
Phone * Required
Email * Required
Usual Schedule * Required
Average Daily Patient Volume * Required
What percentage of your patients are age 11 or older? * Required
Average Patient Acuity * Required

Placement decisions may be influenced by the acuity of patients
Practice Experience (years) * Required
Prescription Authority * Required
- Yes
- No
Precepting Experience (years) * Required
This upload will only accept ".doc" and ".pdf" file extensions. If you have your social security number on any of these documents, please redact it before uploading.
Upload CV, License, and Certification Documents * Required
Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 5 MB.
Word documents and PDF can be uploaded. Please include all three pieces of documentation.
Maximum file size - 5 mega bytes.
Clinical Site
Information on the site where the student will be precepted during the rotation.
Name of Clinical Site * Required
Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone * Required
Hours of Operation * Required
Average Daily Patient Volume * Required
Contact Person
Information on contact person for clinical site.
Name
First Last
Phone
Email

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Clinical Site