Preceptor Letter of Intent

First Name

Last Name

Title

Date

mm/dd/yyyy

Phone

Email

Name of Supervising Physician

Specialty

Clinical Site Address

Practice Setting(s)

Name of Clinical Site

Affiliated Hospital(s)

Patient Demographics

Have you ever taught students in clinical setting?

Are you interested in guest lecturing?

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

How many students can you precept per SCPE?

Availability

Notification of Placement Timeframe

Notes/Comments

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

Acknowledgement

Signature

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Send me a copy of my responses

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