2020 MERIT Clinical Preceptor Sign-up

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Thank you for your interest in becoming a MERIT Clinical Preceptor! This summer, 44 MERIT Scholars (rising juniors) will spend 5 weeks shadowing different health care professionals, like you! These shadowing experiences are often life-changing for our scholars and can ignite a long-term passion for pursuing careers in the health professions. All we ask of our clinical preceptors is to create a welcoming learning environment.

There is NO ADDITIONAL TIME COMMITMENT outside of the shadowing periods. MERIT will take care of all compliance paperwork, HIPAA training, scheduling, etc. for scholars.

Please fill out the following quick survey indicating your preferred contact information, availability, and site details.

This survey will take 5-10 minutes to complete.

Personal Contact Information

Salutation *

Dr.

Mr.

Ms.

Mrs.

Other:

First Name *

Last Name *

Email Address *

Cell Phone Number *

XXX-XXX-XXXX

Administrative Assistant Contact Information (Optional)

First Name

Last Name

Email Address

Cell Phone Number

XXX-XXX-XXXX

General Information

Please select the most appropriate option(s) *

Clinical Preceptor - I am a healthcare provider and I will directly precept MERIT Scholars on the dates I will select below.

Clinical Preceptor Coordinator - I will coordinate clinical experiences in my department with other healthcare providers on the dates I will select below.

Other:

Required

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