Preceptor Profile Form

Thank you for your interest in participating in the education of future Physician Assistants by being a Preceptor! Please complete and submit the form below and we will contact you as soon as possible about how you can join our team.

*required fields

List any other credential(s) not on the above list

123-456-7890

123-456-7890

Please provide the following information about your current practice:

Please identify the individual designated as the point of contact (if other than preceptor)

123-456-7890

Additional Facilities

If students will participate with you beyond your primary facility/clinical site, we must have a complete affiliation agreement for each facility. Please provide the following information so we may confirm an existing or gain affiliation prior to students beginning their rotation with you.

Please enter the contact full name (first and last)

123-456-7890

Interested in other opportunities such as teaching, serving as a guest lecturer, participating in simulation/skill labs, interviewing applicants, serving as a PBL tutor or have a question/comment? 

Please specify in the comment section below:

By submitting this form, I agree to serve as a clinical preceptor for The Kansas State University physician assistant studies program.