CU School of Medicine Foundations of Doctoring Curriculum (FDC) Preceptor Profile

Thank you for your interest in becoming or continuing as a preceptor for CU medical students. This program wouldn't be such a success without outstanding preceptors! Please take a moment to enter your information below. This form helps to ensure that our records are up-to-date. Please contact foundations.doctoring@cuanschutz.edu with any questions.

First Name:*

Last Name:*

Degree(s):

Office Address:

City:

Zip:

Telephone:

Alternate Phone:

Email Address:*

Alternate Email:

Office Manager/Assistant Name:

Office Manager/Assistant Email:

Specialty:

Emergency Medicine

Family Medicine

Hospitalist

Internal Medicine

OB/GYN

Pediatrics

Other

If Other, please describe:

Practice Type/Setting:

Children's Hospital Colorado

Community/Public Health

Denver Health

Kaiser

Private Practice

University Practice

Veterans Affairs

Other Hospital Affiliation

If Private Practice, please list name of practice:

If Other Hospital Affiliation, please specify:

Describe practice (patient demographics, languages spoken, etc.). If other languages are spoken, what percentage of your patient population speaks these languages?

Other information important for us to know in placing a student with you:

Please list any additional practices/settings where the student will need badge access for sessions with you:

How many NEW/ADDITIONAL students are you able to work with this year:

Select or enter value

Please check all days that you are available:

Monday AM

Monday PM

Tuesday AM

Tuesday PM

Wednesday AM

Wednesday PM

Thursday AM

Thursday PM

Friday AM

Friday PM

Evenings/Weekends

I am not interested in participating; please remove my name from your mailing list.

I cannot precept this academic year but would like to be considered for 2021-2022.

Refer a Colleague:

Please contact the doctor listed below who may be interested in being a preceptor:

Colleague's Telephone:

Colleague's Email:

Send me a copy of my responses

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