Jenzabar University

Preceptor Contact Form

Preceptors are an integral part of Rocky Vista University as they give our students hands-on training in the real world with real patients.

First Name

Last Name

Gender

Date of Birth

Race/Ethnicity

Cell Phone

Office Phone

Email Address

Fax Number

Practice Name

Practice Type

If other, please explain:

Practice Address

Does this practice offer TeleMedicine?

Practice City

Practice State

Practice Zip Code

Professional School

Grad Year

Degree Earned (i.e. - DO, MD, PA, ANP, etc.)

Specialty

Certification Type (ABFM, FACOFP, etc.)

Certification Number

Certification Expiration Date

License Number

State

Licensure Type (e.g. Medical)

Licensure Expiration Date

List the hospital(s) used in your clinical practice (to ensure we have appropriate Affiliation Agreements):

Have you had any prior experience precepting/teaching medical students, residents, fellows, nurses, nurse practioners, physician assistants, or EMTs?

Students Accepted for Rotation (REQUIRED):

Would you like an Adjunct Clinical Faculty Appointment from Rocky Vista University?

Please attach your CV below (.docx, .pdf):

Please attach your Certificate of Insurance (COI) below (.docx, .pdf):

If you have issues submitting the form, please remove any commas, spaces, or other special characters from the file, re-upload, and contact us if you are still experiencing problems.

COI Expiration Date

Would you like online access to the Frank Ritchel Ames Memorial Library at Rocky Vista University?

Name of RVU Clinical Coordinator or Student you are working with (if applicable)

Appointment-Position:

Date Credentialed:

Reappointment Date

Notes for Dr. Miller:

Preceptor Activity

Preceptor Databank

Credentialing or Denial Notes