PIER Preceptor Application 2020

ACR and the Commission for Women & Diversity greatly appreciates your interest in serving as a Preceptor and Mentor to our future radiologists and radiation oncologists. Please complete the information below, so that we have the most up to date information for your practice, as well as information needed to onboard smoothly your PIER summer intern. Please complete your application by Friday, January 31, 2020. If you have any questions, please feel free to contact us at PIER@acr.org. Thank you for your support of the ACR PIER Program!

Full Name*

Title

Office phone number

Cell phone number*

E-mail address preferred*

Institution*

Institution Address*

Are you a new Preceptor?*

Select or enter value

Would your institution or department be interested in financially sponsoring an ACR PIER Scholar?

Select or enter value

Subspecialty*

Bibliography and Publications

Please upload your CV below.*

If you have any difficulties uploading your CV or files, please email them to PIER@acr.org

Your administrative assistant's full name*

Your administrative assistant's phone number*

Your administrative assistant's e-mail address*

Co-preceptor's full name

Co-preceptor's e-mail address

Does the PIER Scholar need to complete additional paperwork to participate in clinical, research and/or operating room activities??*

Select or enter value

If you answered yes to the question above, please provide the information needed to onboard your Scholar.

To how many sites will your Scholar travel during their 8-week internship?

Select or enter value

Is lunch available for your Scholar during their 8-week internship?

Select or enter value

Is there free parking available at your internship sites?

Select or enter value

Please upload a recent photo*

If you have any difficulties uploading your photo or files, please email them to PIER@acr.org

File Attachments

Drag and drop files here or

Send me a copy of my responses

Privacy Notice|Report Abuse