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  • Preceptor Profile Form

Preceptor Profile Form

Practice Profile

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

    If preceptor, leave blank
  • I am available to take students during the following dates: Class of 2023
  • I am available to take students during the following dates: Class of 2023
  • Please indicate the number of students you can take in each rotation block.
  • 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

  • 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.
  • Enter as many as applicable
  • Student Requirements

  • **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.
  • Thank you!

    We appreciate the opportunity to partner with you in the education of our students!
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100 Campus Drive | Elon, NC 27244
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