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

Email Address

Date of Birth

Gender

Race/Ethnicity

Cell Phone

Office Phone

Fax Number

Practice Name

Practice Type

If other, please explain:

Practice Address

Practice City

Practice State

Practice Zip

Students Accepted for Rotation (check all that apply):

Professional School

Grad Year

Degree Earned

Other Degree

Specialty

Certification Type (ABFM, FACOFP, etc.)

Certification Number

Certification Expiration Date

Licensure Type (e.g. Medical)

License Number

State

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?

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

Please attach your CV below:

Please attach your Certificate of Insurance (COI) below:

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

Preceptor Documents

Credentialing Checklist