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 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?*YesNoPreceptor Name* First Last Preceptor Credentials*MDDOPANPCNMState License NumberAre you board certified?*YesNoIf certified, year of certificationSpecialty*Preferred method of contact*E-mailOffice PhoneOffice FaxPreferred contact email address* Preferred contact number*Please identify the individual designated as our point of contact (if other than preceptor)If preceptor, leave blankName First Last TitleEmail PhonePractice Setting*Internal MedicineFamily PracticePediatricsSurgeryInpatientEmergency MedicineWomen's HealthBehavioral MedicineRotation Dates*I am available to take students during the following dates: Class of 2021 (February Graduation) 6-week rotations, then 4-week rotations for COVID-19 completions September 8 - October 16, 2020 October 19 - December 4, 2020 December 28, 2020 - January 22, 2021 January 25, 2021 - February 19, 2021 Rotation Dates*I am available to take students during the following dates: Class of 2021 (December Graduation) 6 week rotations January 4 - February 11, 2021 February 15 - March 25, 2021 April 5 - May 13, 2021 June 1 - July 8, 2021 July 12 - August 19, 2021 September 7 - October 14, 2021 October 18 - December 1, 2021 How many students are you able to accommodate?*Please indicate the number of students you can take in each rotation block.(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!