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.

If you see this don't fill out this input box.

First Name*

Last Name*

Other Credentials

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

License Number*

Are you Board/NCCPA Certified?*

Yes

N/A

Date Certified/Recertified

Practice Sepcialty*

Email*

Office Phone

123-456-7890

Cell Phone

123-456-7890

Preferred Method of Contact

Office Phone

Cell Phone

Please provide the following information about your current practice:

Practice/Clinical Site Name*

Address

City

State

Zip

Phone

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

Practice Contact

Contact Phone

123-456-7890

Title

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.

Site/Facility Name

Site Facility Contact Name

Please enter the contact full name (first and last)

Site/Facility Contact Phone

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:

Comments or Questions

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