Preceptor Letter of Intent

Preceptor Letter of Intent

First Name

Last Name

Title

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Date

Phone

Name of Supervising Physician

Specialty

Clinical Site Address

Practice Setting(s)

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Name of Clinical Site

Affiliated Hospital(s)

Patient Demographics

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Have you ever taught students in clinical setting?

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Are you interested in guest lecturing?

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Have you been recruited by P.A.L.S./G.R.O.W.?

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How many students can you precept per SCPE?

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Availability

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Notification of Placement Timeframe

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Notes/Comments

provide additional details (i.e., part-time only, affiliations, rotation preparation resources, etc.)

Acknowledgement

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Signature

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