State of Arizona Grant Program for Preceptors of Healthcare Medical Students

State of Arizona Grant Program for Preceptors of Healthcare Medical 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 one specific Arizona medical student for at least 4 weeks.
Each grant is based on WHEN the preceptorship took place.

If you have received this grant before:

If you have received a grant for a preceptorship that occured between July 1st, 2023 - July 1st, 2024, you may apply for another grant for a 4 week preceptorship that occured between July 1st, 2024 - July 1st, 2025.

If you have not received this grant before:

If you have never received this grant, you may apply for a preceptorship that occured between July 1st, 2023 - July 1st, 2025.

You can receive up to 1 grant for a 4 week preceptorship that occured during 1 academic year (ex: July 2024 - July 2025)

*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 for one preceptorship that took place during one academic year.

To complete this application you will need:
- Your professional license.
- Proof of professional insurance must be an active policy.
- A completed INDIVIDUAL (meaning it goes to you, not your affiliation) W-9 form (don't forget to sign and date halfway down the page!).
  - 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:*
Dates Preceptorship Took Place [must be at least 4 weeks with one particular student] *** If the preceptorship is going to conclude in the FUTURE, please put today's date as the end date (assuming 4 weeks of the preceptorship has passed). Any applications with end dates in the future will be denied*** *
What academic fiscal year did you complete this preceptorship with this student?*

Between July 1st, 2023 - July 1st, 2024Between July 1st, 2024 - July 1st, 2025
Student's Full Name*

First NameLast Name *must provide 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
Provide a brief description of the learning that took place during the preceptorship.*
How did you hear about the State of Arizona Preceptorship Grant Program?*

Word of mouthSocial mediaArMA website or newsletterEmployerArMA staff memberOther

Required Forms

Please attach the required forms below.
A fillable PDF W-9 form can be found here.
Completed W-9 Form. (Don't forget to sign and date!)*

Fill out the W9 as an individual with a social security number. The address you provide on this form is where the grant check will be mailed if approved. Please make sure your W9 is signed and dated before submission!
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Copy of your Professional License.*

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Certificate of Professional Insurance. (Make sure it's up to date!)*

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 LLittrel@azmed.org.
Should be Empty:

State of Arizona Grant Program for Preceptors of Healthcare Medical Students

Preceptor Information

Student Precepted

Healthcare Organization / Site Preceptorship Took Place

Required Forms

Attestation