Preceptor Profile Form

Practice/Clinical Site Name*

Address*

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

Phone Number*

Email*

Average number of patients seen per day/provider*

Preceptor Name*

First Last

Preceptor Credentials*

Upload your CV / Resume

There is a 10MB file size limit. If your CV exceeds this file size, please email to: shenderson13@elon.edu

Accepted file types: doc, docx, pdf, Max. file size: 49 MB.

State License Number*

License issue date & expiration date:*

Are you board certified?*

Yes
No

If board certified, issue and expiration dates:

Specialty:*

Preceptor email address:*

Preceptor phone number:*

How did you hear about the opportunity to precept with the Elon PA Program? (e.g., referred by a colleague, job board, social media, professional organization, Elon representative, etc.) Please specify name below:

If an ALUMNI of Elon PA Program, enter your graduation year here:

Practice Setting*

Family Medicine
Pediatrics
Surgery
Inpatient Medicine
Emergency Medicine
Women's Health
Behavioral Medicine

ARC-PA Setting (select all that apply)*

Outpatient
Inpatient
Operating Room
Emergency Department

Additional Information:

Rural Location
Underserved Population

Availability

Dates for Emergency Medicine, Inpatient, Pediatrics, Primary Care, Surgery, and Elective Rotations:

I am available to take students during the following 6-week timeslots:

Dates for Women's Health & Behavioral Health Rotations:

I am available to take students during the following 3-week timeslots:

How many students are you able to accommodate per rotation?*

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

How many rotations per year can you precept students?*

We appreciate the flexibility of knowing your full availability for assigning placements. If we need to limit the number of placements, please let us know the number of rotations you can commit to taking students over the year.

Honorarium

Is there an honorarium for student experiences? If yes, who is the payee and what is the rate?

Please identify the individual designated as Elon PA Program's point of contact for student onboarding (if other than the Preceptor)

If preceptor, leave blank

Name

First Last

Title

Email

Phone

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

Name

First Last

Title

Email

Phone

Student Requirements

*Elon University PA Program will submit Student Profiles when rotations are confirmed, which contain their contact information, photo, immunization records, flu, drug screen, background check, BLS, ACLS, driver's license, health insurance, and HIPAA/OSHA certification. Please let us know of any additional requirements here:

List the onboarding and training requirements (in addition to what is submitted by Elon) that students will need to complete prior to being on-site.

**Elon University PA Program requires background checks, drug testing, and tuberculosis screenings annually in November, please indicate only if your facility requires more frequent performance of these items.

Additional Facilities

If a student will attend multiple facilities with you, Elon University must have a complete Affiliation Agreement with each facility. Please provide each facility's name and contact person's information so that we are able to meet this requirement prior to the student’s arrival.

Name of Facility, Type of Facility, Contact Person's Name & Email Address:*

Enter as many as applicable

Please enter any notes or additional information you'd like to share:

Thank you!

We appreciate the opportunity to partner with you in the education of our students!

File

Max. file size: 49 MB.

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Email

This field is for validation purposes and should be left unchanged.

Practice Profile

Availability

Please identify the individual designated as Elon PA Program's point of contact for student onboarding (if other than the Preceptor)

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

Student Requirements

Additional Facilities

Thank you!