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

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

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

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)

Appointment-Position:

Date Credentialed:

Reappointment Date

Notes for Dr. Miller:

Preceptor Activity

Preceptor Databank

Credentialing or Denial Notes