GIMSPP Preceptor
Availability Form

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

Yes

Question Title

* 5. Which one(s)?

Question Title

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

Yes

Question Title

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

Primary Specialty

Subspecialty

Neither

Question Title

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

Question Title

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

Question Title

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

SUMMER PRECEPTORSHIPS

Please list the dates for each month that you are UNAVAILABLE to accept students. If no dates are unavailable, please leave this question blank.

Preceptorships last 2-4 weeks during the summer and begin on a Monday and end on a Friday. If you are not available for 2-4 consecutive weeks during May, June, or July this may not be the right program for you.

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

Question Title

* 11. Please list your start date

Unavailable Start Date 1

Unavailable End Date 1

Unavailable Start Date 2

Unavailable End Date 2

Unavailable Start Date 3

Unavailable End Date 3

Pilot Programs

Question Title

* 12. 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

Question Title

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

Yes

I would need more information

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

Question Title

* 5. Which one(s)?

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 11. Please list your start date

Question Title

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

Question Title

* 13. 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