Preceptorship

Thank you for your interest in becoming or continuing as a preceptor for CU 1st-year medical students. This program wouldn't be such a success without outstanding preceptors! Please take a moment to enter your information. This form helps to ensure that our records are up-to-date.

First Name:

Last Name:

Degree(s):

Preferred Email:

Alternate Email:

Do you currently have a Faculty Appointment

Preceptors are required to have a faculty appointment with University of Colorado School of Medicine. If you do not, we will send you information on starting this process. If you are unsure we will look into this and let you know.

CU Alumni

Did you attend the University of Colorado?

Please let us know the name of your practice and hospital affiliation

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:

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

Does your facility require the student to wear a badge issued by your facility?

If Yes, please provide the name and contact information of your badging person.

Yes

Office Manager/Assistant Name:

Office Manager/Assistant Email:

Office Address:

Office Address 2

City:

State:

Zip Code:

Phone:

Alternate Phone:

The students are available to meet with their preceptor on the following days. Please select the days you are available to take a student.

AM=morning PM= afternoon

Flexible Schedule - check this box if you have a flexible schedule and will work with the student when they are available.

Tuesday PM

Wednesday AM

Thursday AM

Friday PM

Weekends

Evenings

How many medical student would you like:

Total number of students you would like to precept

I cannot precept this recruiting cycle, please contact me at a later date

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

Refer a Colleague:

We will send preceptorship information to the doctor listed below who you think may be interested in being a preceptor:

Colleague's Email:

Colleague's Phone:

Send me a copy of my responses

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