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.

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First Name

Last Name

Title:

Gender

Date of Birth

Race/Ethnicity

Cell Phone

Office Phone

Email Address

Fax Number

I have read and acknowledged the RVU Title IX policy.

Practice

Practice Name

Practice Type

If other, please explain:

Practice Address

Does this practice offer TeleMedicine?

Practice City

Practice State

Practice Zip Code

Professional School

Professional School

Grad Year

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

Specialty

Certification

Are you certified?

Certification Type (ABFM, FACOFP, etc.):

Certification Number

Certification Expiration Date

Please attach your certification (.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.

Please explain your reasoning for application without board certification.

Certification Type (ABFM, FACOFP, etc.)

Please explain how you are board eligible:

Certification File - SUSAN ONLY

Licensure

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):

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.

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)

If this form is being submitted on behalf of the preceptor, who is submitting this form?

If you have any questions, please contact Preceptor Staff Services in the Clinical Education Department at shampton@rvu.edu

Program

COM Designation:

PA Designation:

For Dr. Miller

Appointment-Position:

Date Credentialed:

Reappointment Date

Notes for Dr. Miller:

Preceptor Activity

Preceptor Databank

For Susan

Credentialing or Denial Notes