State of Arizona Grant Program for Preceptors of Healthcare Graduate Students

State of Arizona Grant Program for Preceptors of Healthcare Graduate Students
Preceptor Eligibility:

In order to apply for the preceptorship grant program through the Arizona Medical Association you must be an allopathic physician (MD) licensed pursuant to Arizona Revised Statutes, Title 32, and in good standing. Additionally, you must:
- Provide an uncompensated mentoring experience.
- Serve as a volunteer preceptor for an Arizona graduate medical student.
- Precept a training at least four weeks in duration, occurring on or after January 1, 2023. The training must have concluded in order to apply for the grant.
If you have already been awarded a grant, you are eligible for a second year of funding if the preceptorship occurred on or after July 1st, 2023.

*The Arizona Osteopathic Medical Association will be funding osteopathic physician (DO) preceptors. If you are a Doctor of Osteopathic Medicine, please click here to apply via AOMA's application.
Award Amount:

Preceptors are limited to one $1,000 (one thousand dollars) grant per academic fiscal year (July 1 through June 30) regardless of the number of uncompensated preceptorships the applicant provides in that year.
Applicant Instructions:

Applicants may submit one application per academic fiscal year (July 1 - June 30). The preceptorship(s) must have concluded prior to submitting an application.

To complete this application you will need:
- Your professional license.
- Proof of professional insurance must be an active policy.
- A completed W-9 form. A fillable PDF form can be found here.
By providing your signature in the box below, you acknowledge that you have read, understand and meet the eligibility requirements stated above.*

Preceptor Information
Preceptor's Name*

First NameLast Name
Preceptor's Email*
example@example.com
Preceptor's Phone*
Please enter a valid phone number.
Preceptor's Credentials*
Specialty/Focus of Preceptor *
Preceptor's Arizona License Number*
Preceptor's NPI*
Address of Record of Preceptor's License*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Required:*

Student Precepted

Preceptors are limited to one $1,000 (one thousand dollars) grant per academic fiscal year (July 1 - June 30) regardless of the number of uncompensated preceptorships the applicant provides in that year.
Required:*
Student's Full Name*

First NameLast Name *must provide at least one student name for preceptorship verification.
Student's Email*
example@example.com
Select the Arizona Medical School the Student Currently Attends*
Location of Student during Preceptorship*
City, State
Dates Preceptorship Took Place *the preceptorship must have concluded before submitting an application and occurred on or after January 1, 2023.*
Provide a brief description of the learning that took place during the preceptorship.*
How many preceptorship did you provide between January 1, 2023 and now?*

Required Forms

Please attach the required forms below.
A fillable PDF W-9 form can be found here.
Completed W-9 Form. *

Please fill out W9 as an individual, the address you provide on this form is where the grant check will be mailed if approved.
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Copy of your Professional License.*

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Certificate of Professional Insurance.*

Must be an active policy. If insurance is provided by your employer please request the documents from HR. ArMA is not able to contact a preceptor's HR to request documentation.
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Attestation

I have read and completed this application and attest that its contents are true and correct. I understand that if any information is incorrect or missing it may result in a delay of receiving grant funds.
Preceptor Signature*

Clear
Date*

MonthDayYear
Date
Applicants may submit one application per academic fiscal year (July 1 - June 30). Applications will be assessed on a rolling basis. Questions regarding your application can be directed to Hchicoine@azmed.org.
Should be Empty:

State of Arizona Grant Program for Preceptors of Healthcare Graduate Students

Preceptor Information

Healthcare Organization / Site Preceptorship Took Place

Student Precepted

Required Forms

Attestation