Preceptor Profile Form

Practice/Clinical Site Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Average number of patients per day/provider*

Preceptor Name*

First Last

Preceptor Credentials*

Upload your CV/Resume

Accepted file types: doc, docx, pdf, Max. file size: 49 MB.

There is a 10MB file size limit. If your CV exceeds this file size, please email to: shenderson13@elon.edu

State License Number*

Are you board certified?*

Yes
No

Specialty:*

Preceptor email address*

Preceptor phone number*

How did you hear about the opportunity to precept with the Elon PA Program? (e.g., referred by a colleague, job board, social media, professional organization, Elon representative, etc.) Please specify below:

If an ALUMNI of Elon PA program, enter graduation year here:

Practice Setting*

ARC-PA Setting*

Outpatient
Inpatient
Operating Room
Emergency Department

Additional Information

Rural Location
Underserved Population

Availability

6-week Rotation Dates for Emergency Medicine, Family Medicine, Inpatient, Pediatrics, Surgery, and Elective Rotations:

3-week Rotation Dates for Women's Health & Behavioral Health Rotations:

Please indicate the number of students you can take for each rotation block:*

How many rotations per year can you precept students?*

Honorarium - Is there an honorarium for student experiences? If yes, who is the payee and what is the rate?

Please identify the individual designated as Elon PA Program's point of contact for student onboarding (if other than the Preceptor)

Name

First Last

Title

Phone

(Optional) Please provide contact information for the individual who may legally sign the Affiliation Agreement for your facility

Name

First Last

Title

Email

Phone

Student Requirements

*Elon University PA Program will submit Student Profiles when rotations are confirmed, which contain their contact information, photo, immunization records, flu, drug screen, background check, BLS, ACLS, driver's license, health insurance, and HIPAA/OSHA certification. Please list the onboarding and training requirements (in addition to what is submitted by Elon) that students will need to complete prior to being on-site:

**Elon University PA Program requires background checks, drug testing, and tuberculosis screenings annually in November, please indicate only if your facility requires more frequent performance of these items.

Additional Facilities

If a student will attend multiple facilities with you, Elon University must have a complete Affiliation Agreement with each facility. Please provide each facility's name and contact person's information so that we are able to meet this requirement prior to the student’s arrival.

Name of Facility, Type of Facility, Contact Person's Name & Email Address. Enter as many as applicable:*

Please enter any additional information you would like to share:

Thank you!

We appreciate the opportunity to partner with you in the education of our students!

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