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 Dates (Emergency Medicine, Inpatient, Pediatrics, Primary Care, Surgery, Electives)I am available to take students during the following dates: Select All July 10 - August 18, 2023 September 5 - October 13, 2023 October 16 - November 29, 2023 January 8 - February 16, 2024 February 19 - March 29, 2024 April 2 - May 10, 2024 May 28 - July 3, 2024 July 8 - August 16, 2024 September 3 - October 9, 2024 October 14 - November 20, 2024 Rotation Dates (Women's Health & Behavioral Health)I am available to take students during the following dates: Select All 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 January 8 - January 26, 2024 January 29 - February 16, 2024 February 19 - March 8, 2024 March 11 - March 29, 2024 April 2 - April 19, 2024 April 22 - May 10, 2024 May 28 - June 14, 2024 June 17 - July 3, 2024 July 8 - July 26, 2024 July 29 - August 16, 2024 September 3 - September 20, 2024 September 23 - October 9, 2024 October 14 - November 1, 2024 November 4 - November 20, 2024 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! This iframe contains the logic required to handle Ajax powered Gravity Forms.