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* 1. Please enter your contact information below.

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* 2. Preceptor Name

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* 3. After completing your preceptorship, what field do you plan on going into?

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* 4. Are you more likely to enter the field of Internal Medicine as a result of your preceptorship?

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* 5. What day did your preceptorship start?

Date

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* 6. What day did your preceptorship end?

Date

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* 7. How many weeks total was your preceptorship?

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* 8. How would you rate your overall satisfaction with your preceptorship?

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* 9. What is reason for your above rating?

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* 10. Did you and your preceptor establish goals?

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* 11. Did you and your preceptor make reassessments of these and progress toward achieving them?

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* 12. Did your preceptor give you constructive feedback?

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* 13. What is the reason(s) for your above answer?

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* 14. What level of supervision did you receive from your preceptor?

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* 15. What is the reason(s) for your above answer?

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* 16. Approximately how many patients did you interact with IN PERSON with per day?

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* 17. Approximately how many patients did you interact with via TELEMEDICINE with per day?

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* 18. Did the patients accept your presence?

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* 19. Were you introduced to office management, office organization and documentation standards?

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* 20. By the end of the preceptorship, did you perform, assist, and/ or observe the following? Please mark all that apply.

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* 21. Please select which of the following health care professionals/office staff you learned from

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* 22. What is the reason(s) for your above answer?

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* 23. Do you feel that your preceptor's practice gave you adequate exposure to general internal medicine?

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* 24. If you were exposed to subspecialties, please state which one(s).

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* 25. What were your preceptor’s best attributes?

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* 26. How do you feel that your preceptor could improve?

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* 27. What was the most important thing you got out of this experience?

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* 28. Would you recommend this program to other students?

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* 29. What is the reason(s) for your above answer?

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* 30. Did you find the GIMSPP staff to be helpful?

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* 31. What is the reason for the above answer?

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* 32. Would you recommend this program to other students?

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* 33. What is your reason(s) for the above answer?

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* 34. Would you be interested in speaking to  students about your experience?

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* 35. We appreciate any additional comments you may have about the program, your preceptor, or your experience

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* 36. Is it alright to share this evaluation with your preceptor?

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* 37. This survey is subject for review by the Texas Higher Education Coordinating board. I hereby certify that I, (name) - the preceptee/student, am the one who completed this survey.

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