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

Date of Birth

Gender

Race/Ethnicity

Email Address

Fax Number

Cell Phone

Office Phone

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:

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:

Credentialing Checklist