HomeAcademicsHealth SciencesElon PAPreceptor ProgramPreceptor Profile Form Preceptor Profile Form Practice Profile Practice/Clinical Site Name*Address* Street Address City State / Province / Region ZIP / Postal Code Phone Number*Fax NumberEmail* Average number of patients seen per day/provider*Do you routinely evaluate and manage patients for any of the following conditions: depression, anxiety, ADHD, nicotine dependence, substance abuse and other behavioral concerns?*YesNoPreceptor Name* First Last Preceptor Credentials*MDDOPANPCNMState License Number*Are you board certified?*YesNoIf certified, year of certificationSpecialty*Preferred method of contact*E-mailPhonePreferred contact email address* Preferred contact number*Please identify the individual designated as Elon PA Program's point of contact (if other than preceptor)If preceptor, leave blankName First Last TitleEmail PhonePractice Setting*Internal MedicineFamily PracticePediatricsSurgeryInpatientEmergency MedicineWomen's HealthBehavioral MedicineRotation DatesI am available to take students during the following dates: Class of 2023 Select All January 3 - February 10, 2023 February 13 - March 24, 2023 March 27 - May 5, 2023 May 29 - July 7, 2023 July 10 - August 18, 2023 September 5 - October 13, 2023 October 16 - November 29, 2023 Rotation Dates (Women's Health & Behavioral Health)I am available to take students during the following dates: Class of 2023 Select All January 3 - January 20, 2023 January 23 - February 10, 2023 February 13 - March 3, 2023 March 6 - March 24, 2023 March 27 - April 14, 2023 April 17 - May 5, 2023 May 30 - June 16, 2023 June 19 - July 7, 2023 July 10 - July 28, 2023 July 31 - August 18, 2023 September 5 - September 22, 2023 September 25 - October 13, 2023 October 16 - November 3, 2023 November 6 - November 29, 2023 How many students are you able to accommodate?*Please indicate the number of students you can take in each rotation block.Site feesDoes your site charge for student experiences? If so, what is the rate?Is there a preceptor honorarium for student experiences that would be paid to you or your facility? If yes, who is the payee and what is the rate?(Optional) Please provide contact information for the individual who may legally sign the affiliation agreement for your facilityName First Last TitleEmail PhoneAdditional FacilitiesIf a student will participate with you in inpatient care in a hospital, rehabilitation or nursing facility, surgical center, emergency department, we must have a complete affiliation agreement for each facility. Please provide the facility name and, if known, the contact name and phone number so that we may accomplish this prior to the student’s arrival.Name of Facility, Type of Facility, Contact Person, Phone*Enter as many as applicableStudent RequirementsDoes your facility require...?**Elon University DPAS performs background checks and tuberculosis screenings annually in November, please indicate only if your facility requires more frequent performance of these items. Security Clearance Site/facility specific student ID Facility computer access and/or training Student pre-placement drug testing **Pre-placement tuberculosis screening **Proof of student background check Other List Other:Thank you!We appreciate the opportunity to partner with you in the education of our students!