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* 1. Please enter your contact information below.

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* 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

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* 3. Which best describes your type of practice?

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

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* 5. Which one(s)?

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

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

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

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

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* 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.

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* 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

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

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

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