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Preceptor Interest Application
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.
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Email
*
Your email
What is your full name?
*
Your answer
What is your phone number?
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Your answer
What is your license type?
*
Nurse Practitioner
Physician
CNM
Other:
Do you hold national board certification?
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Yes
No
What is your primary specialty? (i.e. family, internal medicine, pediatrics)
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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?
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Yes
No
Clinical Site Address
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Your answer
Clinical Site City
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Your answer
Clinical Site State
*
Your answer
Clinical Site Zip code
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Your answer
When are you available?
*
Your answer
Any other notes or preferences that you would like us to be aware of?
Your answer
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