Preceptor Profile Form

Practice/Clinical Site Name*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Phone Number*

Fax Number

Email*

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?*

Yes
No

Preceptor Name*

First Last

Preceptor Credentials*

State License Number*

Are you board certified?*

Yes
No

If certified, year of certification

Specialty*

Preferred method of contact*

E-mail
Phone

Preferred 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 blank

Name

First Last

Title

Email

Phone

Practice Setting*

Rotation Dates (Emergency Medicine, Inpatient, Pediatrics, Primary Care, Surgery, Electives)

I am available to take students during the following dates:

Rotation Dates (Women's Health & Behavioral Health)

I am available to take students during the following dates:

How many students are you able to accommodate?*

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

Site fees

Does 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 facility

Name

First Last

Title

Email

Phone

Additional Facilities

If 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 applicable

Student Requirements

Does 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!

Practice Profile

Please identify the individual designated as Elon PA Program's point of contact (if other than preceptor)

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

Additional Facilities

Student Requirements

Thank you!