Welcome to the Butler PA Program! We are thrilled you will be joining us as a preceptor.
This form is not intended to be a contract but a step required for PA program accreditation. Once your information is received, we can begin securing Affiliation Agreement(s) with the site(s) where you practice and intend to involve the student learner.
You will be asked to provide the following information within this form:
- Your Professional Information (name, credentials, medical license number, contact info) Please note, if you are a PA-C or NP, you will be asked to provide the same information for your collaborating physician.
- Site Information (business name, physical address, phone number, secondary contact info)
- Affiliated Site Names (if applicable)
- Basic Patient Population and Practice Setting Information
- Agreement of Responsibilities statement
Upon completing this form, you will receive a copy for your records.Thank you in advance for your support of the Butler University PA Program.
