GIMSPP Preceptor
Availability Form

Eligibility Requirements:

Preceptor must be board certified in internal medicine with a current Texas medical license.
Preceptors must practice at least 40% as a general internist apart from any other sub-specialties.
Preceptors are expected to provide daily, personal instruction and supervision to a medical student.
Preceptor time commitment ranges from two (2) to four (4) weeks during the summer.

Question Title

* 1. Please enter your contact information below.

Name

Practice Name

Practice Address

Practice Address 2

Practice City/Town

Practice State/Province

Practice ZIP/Postal Code

Email Address

Phone Number

Question Title

* 2. Please enter your office administrator's contact information here.

We will contact them to verify affiliation agreements, paperwork, training, etc. needed for students to precept with you

Administrator Name

Administrator Email Address

Administrator Phone Number

Question Title

* 3. Which best describes your type of practice?

Solo practice

Group Practice

Employed Physician/Hopsitalist

Single Specialty

Multi-Specialty

Emergency Care Clinic

Medical Home

Question Title

* 4. Is your practice/clinic/hospital affiliated with any of the medical schools for students?

BCM - Baylor College of Medicine

EnMed - Texas A&M College of Engineering, College of Medicine

PLFSOM - Texas Tech University Health Sciences Center Paul L. Foster School of Medicine

SHSUCOM - Sam Houston State University College of Osteopathic Medicine

TAMUHSC - Texas A&M Health Science Center College of Medicine

TCU - TCU Burnett School of Medicine

TTUHSC - Texas Tech University Health Sciences Center School of Medicine

UHCOM - University of Houston College of Medicine

UIWSOM - University of the Incarnate Word School of Osteopathic Medicine

UNTHSC - University of North Texas Health Science Center at Fort Worth/Texas College of Osteopathic Medicine

UTDell - The University of Texas at Austin-Dell Medical School

UTHealth - The University of Texas Health Science Center at Houston McGovern Medical School

UTHSCSA - The Joe R. and Teresa Lozano Long University of Texas School of Medicine at San Antonio

UTMB - The University of Texas Medical Branch at Galveston

UTRVG - The University of Texas Rio Grande Valley Medical School

UTSW - The University of Texas Southwestern Medical Center

No, we are not affiliated with any medical school. I can precept a student from any program.

Question Title

* 5. Are you affiliated with a healthcare system or hospital other than the one listed in your contact information?

Yes

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* 6. Which one(s)?

Question Title

* 7. Do you spend at least 40% of your time practicing general Internal Medicine?

Yes

Question Title

* 8. Is Internal Medicine your primary specialty or subspecialty?

Primary Specialty

Subspecialty

Neither

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* 9. Please list any specialties you have other than Internal Medicine.

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* 10. Were you invited to participate in GIMSPP by a student? Please let us know their name to facilitate the match process.

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* 11. How many students will you accept at one time?

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* 12. How many students can you accept over the course of the summer?

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* 13. Do students need to speak another language to participate effectively in your practice?

Yes (Please specify)

SUMMER PRECEPTORSHIPS

Matches are made between May - August.

Please list dates below if there are any dates that you would not be available to accept students. If no dates are unavailable, please leave this question blank.

Preceptorships last two (2) to four (4) consecutive weeks during the summer and begin on a Monday and end on a Friday.

Our most requested dates from Medical Students are in late-May and throughout June.

Question Title

* 14. If you have any dates that you would be unable to participate this, please let us know below. We will always confirm the match dates before we finalize a match, but this helps us plan in advance.

Unavailable Start Date 1

Date

Unavailable End Date 1

Date

Unavailable Start Date 2

Date

Unavailable End Date 2

Date

Unavailable Start Date 3

Date

Unavailable End Date 3

Date

Question Title

* 15. Please let us know if there are anything students may need to know or provide before beginning their preceptorship. Examples have but not limited to providing their own PPE; vaccine records; HIPPA training; an application for the hospital to approve.

Pilot Programs

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* 16. Are you interested in taking a student for one day per week during the semester for a total of 20 days?

Yes

I would need more information

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* 17. Are you interested in taking a student during the winter break between December and January?

Yes

I would need more information

GIMSPP PreceptorAvailability Form

Question Title

* 1. Please enter your contact information below.

Question Title

* 2. Please enter your office administrator's contact information here.We will contact them to verify affiliation agreements, paperwork, training, etc. needed for students to precept with you

Question Title

* 3. Which best describes your type of practice?

Question Title

* 4. Is your practice/clinic/hospital affiliated with any of the medical schools for students?

Question Title

* 5. Are you affiliated with a healthcare system or hospital other than the one listed in your contact information?

Question Title

* 6. Which one(s)?

Question Title

* 7. Do you spend at least 40% of your time practicing general Internal Medicine?

Question Title

* 8. Is Internal Medicine your primary specialty or subspecialty?

Question Title

* 9. Please list any specialties you have other than Internal Medicine.

Question Title

* 10. Were you invited to participate in GIMSPP by a student? Please let us know their name to facilitate the match process.

Question Title

* 11. How many students will you accept at one time?

Question Title

* 12. How many students can you accept over the course of the summer?

Question Title

* 13. Do students need to speak another language to participate effectively in your practice?

Question Title

* 14. If you have any dates that you would be unable to participate this, please let us know below. We will always confirm the match dates before we finalize a match, but this helps us plan in advance.

Question Title

* 15. Please let us know if there are anything students may need to know or provide before beginning their preceptorship. Examples have but not limited to providing their own PPE; vaccine records; HIPPA training; an application for the hospital to approve.

Question Title

* 16. Are you interested in taking a student for one day per week during the semester for a total of 20 days?

Question Title

* 17. Are you interested in taking a student during the winter break between December and January?

GIMSPP Preceptor
Availability Form

* 2. Please enter your office administrator's contact information here.

We will contact them to verify affiliation agreements, paperwork, training, etc. needed for students to precept with you