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Advanced Practice Provider (APP) IBD Preceptorship Host Site Interest Form

If you represent an IBD Center with one or more APP's working independently in the area of IBD, and are interested in joining our APP IBD Preceptorship Program as a participating host site, we invite you to please complete this form. Please direct any questions you may have to: App@crohnscolitisfoundation.org
1.Institution Full Name (Required.)
2.Clinic Address (Required.)
3.GI Department Phone Number(Required.)
4.GI Department Website URL (Required.)
5.GI Department Chairperson (Required.)
6.Name & credentials of GI Advanced Practice Provider Lead Assigned to APP Preceptorship Program
7.Email address of GI Advanced Practice Provider Lead Assigned to APP Preceptorship Program(Required.)
8.Phone number of GI Advanced Practice Provider Lead Assigned to APP Preceptorship Program
9.Approximate number of IBD Patients seen as outpatients in an average month(Required.)
10.Approximate number of IBD Patients seen as inpatients in an average month(Required.)
11.Number of IBD Physicians involved in outpatient management (Required.)
12.Number of IBD Physicians involved in inpatient consultation/ services (Required.)
13.Number of IBD Advanced Practice Providers involved in outpatient management (Required.)
14.Number of IBD Advanced Practice Providers involved in inpatient consultation/ services (Required.)
15.Do your Advanced Practice Providers practice independently?(Required.)
16.Which population does your clinic/institution serve?(Required.)
17.Does your clinic host any weekly/monthly IBD conferences or meetings? Please describe. (Required.)
18.Do you have a multidisciplinary focus in IBD patient care management? (Dietician, Psychologist, Surgeon,  etc.)(Required.)
19.Does your institution perform basic research in IBD?(Required.)
20.Does your institution perform clinical research in IBD?(Required.)
21.The APP Preceptorship program hosts 3-4 preceptees at each host institution for 3 consecutive days. Do you anticipate any logistical problems with this?(Required.)
22.The GI Advanced Practice Provider assigned to this role may be required to score applications. Do you anticipate any logistical problems with this?(Required.)
23.If your site is selected, please indicate the month(s) that work best for you to host preceptees. (Select all that apply.)(Required.)
24.Please provide a brief overview on why your institution is interested in becoming a host site for the APP Preceptorship Program.(Required.)
25.Please include any additional information you would like to speak to. (Required.)