New Preceptor Form
Preceptor Profile
Prefix
Please Select
Dr.
Mr.
Ms.
Mrs.
Mx.
Name
*
First Name
Last Name
Graduate of Le Moyne College?
*
Yes
No
Undergraduate Degree Year
Graduate Degree Year
Email
*
example@example.com
Preceptor Credentials
*
MD
DO
PA
NP
CNM
Is Preceptor Board Certified?
*
Yes
No
N/A
Do you currently use MAT on in your daily practice?
Yes
No
Upload a current CV
*
Browse Files
Drag and drop files here
Choose a file
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of
Clinical Dates Available (Select all that apply)
*
08/28/23 – 09/28/23
10/02/23 – 11/02/23
11/06/23 – 12/07/23
01/08/24 – 02/08/24
02/12/24 – 03/14/24
03/18/24 – 04/18/24
04/29/24 – 05/30/24
06/03/24 – 07/04/24
07/15/24 – 08/08/24
I am interested in precepting students but cannot commit to specific dates at this time. Please contact me when needed
Type of Rotation
*
Family Practice
Women’s Health
Pediatrics
Emergency Medicine
Internal Medicine
General Surgery
Behavioral & Mental Health
Other
Do you want to work with a particular student? If yes, please enter their name
Does Le Moyne College already have an affiliation agreement with your practice site(s)?
*
Yes
No
Practice Profile
Practice/Site Name
*
Practice/Site Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Office Contact Name
*
First Name
Last Name
Office Contact Prefix
Please Select
Dr.
Mr.
Ms.
Mrs.
Mx.
Office Contact Email
*
example@example.com
Office Phone Number
*
Please enter a valid phone number.
Office Fax Number
Please enter a valid phone number.
Preferred Contact Method
*
Phone
Email
Will the PA student accompany the preceptor to a hospital, surgery center, or additional locations?
*
Yes
No
Site Name (1)
Site Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Person to contact for credentialing
First Name
Last Name
Contact Email
example@example.com
Contact Phone
Please enter a valid phone number.
Add an additional location?
Yes
No
Site Name (2)
Site Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Person to contact for credentialing
First Name
Last Name
Contact Email
example@example.com
Contact Phone
Please enter a valid phone number.
Add an additional location?
Yes
No
Site Name (3)
Site Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Person to contact for credentialing
First Name
Last Name
Contact Email
example@example.com
Contact Phone
Please enter a valid phone number.
Add an additional location?
Yes
No
Site Name (4)
Site Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Person to contact for credentialing
First Name
Last Name
Contact Email
example@example.com
Contact Phone
Please enter a valid phone number.
Add an additional location?
Yes
No
Site Name (5)
Site Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Person to contact for credentialing
First Name
Last Name
Contact Email
example@example.com
Contact Phone
Please enter a valid phone number.
Add an additional location?
Yes
No
Site Name (6)
Site Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Person to contact for credentialing
First Name
Last Name
Contact Email
example@example.com
Contact Phone
Please enter a valid phone number.
Practice Demographics
Daily Census: Please list below the average number of patients seen daily.
*
Patient Population Distribution by age
*
Percentage
Pediatrics (0-12)
Adolescents (13-17)
Adults (18-65)
Geriatrics (65+)
Percent of Preceptor’s Time Spent in Settings Below
*
Percentage
Office
Clinic
Hospital
Nursing Home
Does a significant portion of your patient population speak a language other than English?
*
Yes
No
Languages
What other providers in the office will the student work with?
*
MD
DO
PA
NP
CNM
None of the Above
Other
Is there student housing available in your area?
Yes
No
N/A (site is located within 50mi of Syracuse, NY)
Please provide contact name, phone, email
Practice/Student Requirements
Please note: Le Moyne College maintains standard liability insurance in an amount not less than $1 million to $3 million per occurrence.
What specific items must the PA student complete prior to the start of a clinical rotation with you? (background check, drug screen, PPD, etc.)
*
Do you require that the PA student complete a particular clinical rotation before the start of a rotation with you? (i.e., general surgery before emergency medicine?
*
Yes
No
Please Explain
Do you recommend that the PA student review any particular texts/articles to help the student be successful during a clinical rotation with you?
*
Yes
No
Please Explain
Will the PA student be given the opportunity for hands-on patient contact?
*
Yes
No
Will the PA student be allowed to write in charts and/or utilize the EMR?
*
Yes
No
Will the PA student have the opportunity to take call?
*
Yes
No
Are you able to provide a minimum of 36 hours per week of clinical/O.R. time?
*
Yes
No
For women’s health providers, would you be willing to precept male PA students?
Yes
No
N/A
Have you taken PA students and/or medical students in the past?
*
Yes
No
Is there any additional information you would like to share with us?
*
Yes
No
Please share any additional information/comments
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