Preceptor Update Form

This form is an annual update form for preceptors to provide availability and updated contact information for use in matching students for pediatric preceptorships. We will contact you when, and if we have a match to verify your availability and willingness to accept a student before we contact the student.  No student will be matched with you without your prior approval.

Address, City, State, Zip, Phone and Fax:
If you do not know or would like to verify, You may verify your status via address through the HRSA website, https://datawarehouse.hrsa.gov/tools/analyzers/geo/ShortageArea.aspx.
If you do not know or would like to verify, you may verify your status via address through the HRSA website, https://datawarehouse.hrsa.gov/tools/analyzers/geo/ShortageArea.aspx.
If your practice is in a large metro area please indicate part of town (downtown, near medical center, etc.)?
List any special characteristics of practice (Spanish-speaking, primarily treat chronically ill children, etc.)?
Part-time physicians should share their preceptee with a partner.
Please list below any times that you know you are unavailable to be a preceptor.
List the name of your office manager or nurse if applicable.