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*

Licesne issue date and expiration date*

Are you board certififed?*

Yes
No

If certified, year of certification

Specialty*

Preceptor Email Address*

Preceptor phone number*

If referred by someone to precept with Elon PA Program, enter their name here:

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

Practice Setting*

Primary Care (Family or Internal Medicine)
Pediatrics
Surgery
Inpatient Medicine
Emergency Medicine
Women's Health
Behavioral Medicine

ARC-PA Setting*

Outpatient
Inpatient
Operating Room
Emergency Department

Additional Information

Rural Location
Underserved Population

Availability

Dates for Emergency Medicine, Inpatient, Pediatrics, Primary Care, Surgery, and Elective Rotations:

I am available to take students during the following 6-week timeslots:

Dates for Women's Health & Behavioral Health Rotations:

I am available to take students during the following 3-week timeslots:

How many students are you able to accomodate per rotation?*

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

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)

If preceptor, leave blank

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 let us know of any additional requirements here:

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 notes of 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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