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Preceptor Form

*Required fields

Preceptor Profile:

*Preceptor First Name:
*Preceptor Last Name:
*Preceptor Credentials:

 If Other: 
Florida License Number:
*Board/NCCPA Certified:

Date Certified/Recertified:
*Preceptor Practice Specialty: 
*Email Address:
Office Phone:
Cell Phone:  
What is your preferred method of contact? 

Practice Profile:  

*Practice/Clinical Site Name:  
Street Address:
City:  
State:
ZIP Code:
Phone:
Email:

Please identify the individual designated as the point of contact (if other than preceptor).

Practice Contact Name: 
Contact Phone:
Title:
Email:

Additional Facilities

If students will participate with you beyond your primary facility/clinical site, we must have a complete affiliation agreement for each facility. Please provide the following information so we may confirm an existing or gain affiliation prior to students beginning their rotation with you.

Site/Facility Name:
Site/Facility Contact First Name:
Site/Facility Contact Last Name:
Site/Facility Contact Phone:
  
Interested in other opportunities such as teaching, serving as a guest lecturer, participating in simulation/skill labs, interviewing applicants, serving as a PBL tutor or have a question/comment?
Please specify in the comment section below:

By submitting this form, I agree to serve as a clinical preceptor for The University of Tampa physician assistant medicine program.