CMU MPAS Program Preceptor Intent Form

Colorado Mesa University Physician Assistant Program
Preceptor & Site Profile
Name of Practice/Facility
Address

Address

Street Address Line 2

CityState

Zip
Office Administrator Name
Phone
Email
example@example.com
Primary Preceptor Name*
Primary Preceptor Email*
example@example.com
Phone
Primary specialty
Secondary specialty
Medical License Number
Issuing state
Expiration date

MonthDayYear
Date
Board Certified
Board Eligible
If Nurse Practitioner – Date of Birth*

MonthDayYear
Date
*Please provide DOB as required to obtain board certification verification
Professional/Medical school name
Practiced at least 2 years in this specialty

YesNo
Other Site Privileges hospital, surgical center, etc
If PA, Supervising Physician Name
How many students per clinical year (June-May) are you comfortable precepting?*
The responsibilities of the Primary Preceptor include orientation of the student within their facility, supervision of the student as they complete rotations with yourself and other providers, as well as completing an end-of-rotation student evaluation.
I accept these responsibilities:

YesNo
Do you currently have any sanctions against your facility from any third-party program or government agency?

NoYes
If yes, please attach a letter of explanation.
File Upload

Cancelof
Signature

Clear
Typed Name
Title
Date

MonthDayYear
Date
Please attach current CV and copy of license & certification

Cancelof
* The ARC-PA has granted Accreditation-Provisional status to the Colorado Mesa University Physician Assistant Program sponsored by Colorado Mesa University. Accreditation-Provisional is an accreditation status granted when the plans and resource allocation, if fully implemented as planned, of a proposed program that has not yet enrolled students appear to demonstrate the program’s ability to meet the ARC-PA Standards or when a program holding Accreditation- Provisional status appears to demonstrate continued progress in complying with the Standards as it prepares for the graduation of the first class (cohort) of students. Accreditation-Provisional does not ensure any subsequent accreditation status. It is limited to no more than five years from matriculation of the first class.
Primary Preceptor Name_EmailError*
Should be Empty:

Colorado Mesa University Physician Assistant Program