Preceptor Interest Application

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Thank you for your interest in joining USU's Preceptor Community. Please fill out the information below and we will contact you with any next steps.

Email *

What is your full name? *

What is your phone number? *

What is your license type? *

Nurse Practitioner

Physician

CNM

Other:

Do you hold national board certification? *

Yes

What is your primary specialty? (i.e. family, internal medicine, pediatrics) *

Family/Primary Care (across the lifespan)

Primary Care - Adult/Internal Medicine

Pediatrics

Geriatrics

Women’s Health, OB/GYN

Urgent Care

Other:

Do you have 1 or more years of professional experience at the level of current licensure? *

Yes

Clinical Site Address *

Clinical Site City *

Clinical Site State *

Clinical Site Zip code *

When are you available? *

Any other notes or preferences that you would like us to be aware of?

Submit

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