Preceptor Contact Form

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

*

Male
Female

Date of Birth

*

Race/Ethnicity

Cell Phone

*

Office Phone

*

Email Address

*

Fax Number

Practice

Practice Name

*

If other, please explain:

Practice Address

*

Does this practice offer TeleMedicine?

*

Yes
No

Practice City

*

Practice State

*

Practice Zip Code

*

Professional School

*

Grad Year

*

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

*

Specialty

*

Certification

Certification Type (ABFM, FACOFP, etc.)

*

Certification Number

*

Certification Expiration Date

*

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?

*

Yes
No

Students Accepted for Rotation (REQUIRED):

*

Third-year medical students
Fourth-year medical students
Physician Assistant students

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

*

Yes
No

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.

Choose a file

COI Expiration Date

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

*

Yes
No

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

If you have any questions, please contact the Department of Clinical Education at 720-875-2838 or credentialing@rvu.edu

Jenzabar University

Clinical Education