Personal Information

Legal First Name

Preferred First Name

Middle Initial

Legal Last Name

Work Email

Personal Email

Degree

State In Which Licensed

Board Certification

Please specify certifying body

Area of Practice

If Elective, please specify:

Hospitals (credentialed)

Referred To This Site By

Office Information

Office Name

Office Manager/Administrative Contact

Office Contact Email

Office Address 1

Office Address 2

Office City

Office State

Office Zip Code

Office Phone

Office Fax

Rotation Expectation Information

The clinical rotation experience for a PA student assigned to follow you will last up to 5 weeks long. The student will follow your work schedule and it is the programs expectation that the student will be responsible to communicate with you if he or she will be absent from any part of the clinical rotation. Thank you for your willingness to carry forward your knowledge and expertise in medicine with our students. A representative from the School of PA Medicine will be contacting you to arrange a meeting to discuss this opportunity and answer any questions you might have regarding this supervised clinical rotation experience.

Please enter the maximum number of students you are willing to precept each year.

Guest Speaker

Subjects Interested In

Type of Lecture

VirtualFace-to-FaceSkills Lab

Dates Available to Speak

Committee/Program Interest

Which of the following activities would you be interested in?

AdmissionsExternal Advisory CommitteeProcedure/Skills Training None of the above

Comments/Questions

Do you have any additional comments or questions, please let us know below:

Disclaimer

I understand that my electronic signature indicates my willingness to become a preceptor for Northwest University PA Students. I further understand the School of PA Medicine will require a mid-rotation and final rotation evaluation of the assigned PA student. The amount of time a student is assigned will not go beyond 5 weeks per rotation and the School of PA medicine will communicate the exact dates prior to accepting the student assignment. A brief orientation between the university and the preceptor will be required prior to accepting any student rotation.

Yes, I understand and agree to these terms

Electronic Signature

Type Name