PA Preceptor Profile

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Student Expectations

Location & Time to Report*

First day of rotation

Can you provide a minimum of 200 hours per rotation? (Expected minimum of 40 hours per week)*

Yes No

If the 40 hours per week cannot be met the following learning opportunities can used to supplement their learning and hours on the rotation. In this instance, which additional learning opportunities will students be provided?*

Lectures Grand rounds Directed reading/research

Other:

Check all that apply

On-Call Requirements*

Weekend Requirements*

Site Specific Requirements

Your recommendations for a student to prepare in advance for this rotations

Practice Information

Site Name*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Office Contact

Position/Function

Email Address*

Phone*

Fax

Other methods of contact

Patients seen in hospital?*

Yes No

Please list Hospital Affiliation 1 where the student will see patients*

Please list Hospital Affiliation 2 where the student will see patients

Are you employed by a contracting group outside of this site?*

Yes No

Group Name*

Preceptor Information

Student Expectations

Practice Information

Practice Profile