TidalHealth Preceptor Request

TidalHealth Preceptor Request

Last Name, First Name*

Are you currently employed by TidalHealth?*

Yes

University Name:*

Current Program Enrollment*

MD/DO

SRNA

CNM

Other (please specify)

If selected "Other" above, please specify:

Email Address*

Please select from the options below:*

I am local to the area

I am not a local of the Eastern Shore MD/DE

If local, please provide City/State*

Put n/a if not applicable

Rotation Information

Requested Rotation Dates or Semester Dates*

Dates must be specific (we cannot accept a request if only months are provided)

Are you requesting a continuous rotation?*

If selecting no, you must answer the next two questions. If yes, please continue to specialty type.

Yes

Total number of hours needed:

Total days/hours per week needed:

i.e. One 8 hour day per week

Department of Interest*

for internal medicine please identify inpatient or outpatient.
for behavioral health please identify adult or c/a inpatient, outpatient, or psychotherapy

Preceptor Type*

Physician

Physician Assistant

Nurse Practitioner

Nurse Anesthetist

Nurse Midwife

Other (please specify)

If selected "Other' above, please specify

Provider*

Have you already spoken to a provider who is interested in being your preceptor?

Yes (please specify)

If selected "Yes" above, please specify

What racial or ethnic group best describes you?

TidalHealth embraces diversity and inclusion and continues to work toward health equity for everyone on Delmarva.

You are not obligated to answer this question, however, if you are comfortable, please provide a response.

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or Pacific Islander

White

Other

File Upload*

Required documents:

Curriculum Vitae (CV)
Cover Letter

Drag and drop files here or

Send me a copy of my responses

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