Preceptor Letter of Intent

First Name *

Last Name *

Title *

Date *

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 PALS/GROW/MAPS *

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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