New Preceptor Form

New Preceptor Form
Preceptor Profile
Prefix
Name*

First NameLast Name
Graduate of Le Moyne College?*

YesNo
Undergraduate Degree Year
Graduate Degree Year
Email*
example@example.com
Preceptor Credentials*

MDDOPANPCNM
Is Preceptor Board Certified?*

YesNoN/A
Do you currently use MAT on in your daily practice?

YesNo
Upload a current CV*

Cancelof
Clinical Dates Available (Select all that apply)*

08/28/23 – 09/28/2310/02/23 – 11/02/2311/06/23 – 12/07/2301/08/24 – 02/08/2402/12/24 – 03/14/2403/18/24 – 04/18/2404/29/24 – 05/30/2406/03/24 – 07/04/2407/15/24 – 08/08/24I am interested in precepting students but cannot commit to specific dates at this time. Please contact me when needed
Type of Rotation*

Family PracticeWomen’s HealthPediatricsEmergency MedicineInternal MedicineGeneral SurgeryBehavioral & Mental HealthOther
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)?*

YesNo
Practice Profile
Practice/Site Name*
Practice/Site Address*

Street Address

Street Address Line 2

CityState

Zip Code
Office Contact Name*

First NameLast Name
Office Contact Prefix
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*

PhoneEmail
Will the PA student accompany the preceptor to a hospital, surgery center, or additional locations?*

YesNo
Site Name (1)
Site Address

Street Address

Street Address Line 2

CityState

Zip Code
Person to contact for credentialing

First NameLast Name
Contact Email
example@example.com
Contact Phone
Please enter a valid phone number.
Add an additional location?

YesNo
Site Name (2)
Site Address

Street Address

Street Address Line 2

CityState

Zip Code
Person to contact for credentialing

First NameLast Name
Contact Email
example@example.com
Contact Phone
Please enter a valid phone number.
Add an additional location?

YesNo
Site Name (3)
Site Address

Street Address

Street Address Line 2

CityState

Zip Code
Person to contact for credentialing

First NameLast Name
Contact Email
example@example.com
Contact Phone
Please enter a valid phone number.
Add an additional location?

YesNo
Site Name (4)
Site Address

Street Address

Street Address Line 2

CityState

Zip Code
Person to contact for credentialing

First NameLast Name
Contact Email
example@example.com
Contact Phone
Please enter a valid phone number.
Add an additional location?

YesNo
Site Name (5)
Site Address

Street Address

Street Address Line 2

CityState

Zip Code
Person to contact for credentialing

First NameLast Name
Contact Email
example@example.com
Contact Phone
Please enter a valid phone number.
Add an additional location?

YesNo
Site Name (6)
Site Address

Street Address

Street Address Line 2

CityState

Zip Code
Person to contact for credentialing

First NameLast 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?*

YesNo
Languages
What other providers in the office will the student work with?*

MDDOPANPCNMNone of the AboveOther
Is there student housing available in your area?

YesNoN/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?*

YesNo
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?*

YesNo
Please Explain
Will the PA student be given the opportunity for hands-on patient contact?*

YesNo
Will the PA student be allowed to write in charts and/or utilize the EMR?*

YesNo
Will the PA student have the opportunity to take call?*

YesNo
Are you able to provide a minimum of 36 hours per week of clinical/O.R. time?*

YesNo
For women’s health providers, would you be willing to precept male PA students?

YesNoN/A
Have you taken PA students and/or medical students in the past?*

YesNo
Is there any additional information you would like to share with us?*

YesNo
Please share any additional information/comments
I consent to receive additional emails from the Le Moyne College PA Department regarding Preceptor Events and Le Moyne program updates. I understand that I can revoke my consent to receive emails at any time by using the SafeUnsubscribe® link, found at the bottom of every email.

Yes
Should be Empty:

New Preceptor Form

Preceptor Profile

Practice Profile

Practice Demographics

Practice/Student Requirements