Preceptor Interest Form

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Thank you for expressing interest in teaching the CSS PA students! Please complete the questions below if you are interested in becoming a preceptor for the CSS PA program.

Email *

Name (Last, First) *

Degree *

Number of years in practice *

Medical Specialty *

Currently Board-certified? *

Yes

If Yes, please indicate specialty board.

Phone Number *

Work Address *

Are you interested in:

Shadowing experience; a gradual introduction to the clinical environment; 4 hours monthly for 9 months

Clinical rotation experience under your supervision; one or more 6 week rotations throughout the year.

Lecturing for students in your area of specialty during the didactic phase.

Would you be interested in participating in a 5 hour training webinar for clinical rotation preceptors? *

Yes

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