GIMSPP Preceptor Availability Form

Fields marked with * are required.

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First Name *
Last Name *
Designation(s)(use Ctrl or Shift to Select More than One) *
Gender *
Your E-mail: *
Cell Phone (to be used for office scheduling purposes only) *
My student can have access to my cell phone and contact me. *

Clear Selection
Name of Clinic/Practice *
Practice Web Address *
What best describes your type of practice? *
Are you affiliated with a health care system? If yes, please enter the name.
Is Internal Medicine your Primary specialty or Subspecialty? *
Please list any other specialties you have.
Office Address *
City *
State *
Zip *
Office Contact First and Last Name: *
Office Contact's Number *
Office Contact's Email *

Pilot Programs

We are considering extending our reach into the semester, offering both semester-long opportunities as well as possible winter and spring break preceptorships.  If you respond that you are able to accommodate students during this time, you will be first on our list should be start these preceptorships in 2018.

Are you interested in taking a student for one day per week during the semester for a total of 4 weeks? *
Are you interested in taking a student during winter break between December and January? *
Are you interested in taking a student in March-April for a student's spring break? *

Summer Preceptorships

Blackout Availability Dates

Please list the dates for each month that you are UNAVAILABLE to accept students.  If no dates are unavailable, please indicate NA.  We will try to schedule students around your vacation time. 

Preceptorships last anywhere from 3 to 4 weeks, depending on student availability - if you are not available for 3-4 consecutive weeks during any of the months listed, please do not apply.  Students generally request most for dates in June.

Unavailable dates in May (list as MM/DD - MM/DD if applicable; if not applicable, state NA):
(Maximum characters: 2000)
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Unavailable dates in June (list as MM/DD - MM/DD if applicable; if not applicable, state NA):
(Maximum characters: 2000)
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Unavailable dates in July (list as MM/DD - MM/DD if applicable; if not applicable, state NA):
(Maximum characters: 2000)
You have characters left.
Unavailable dates in August (list as MM/DD - MM/DD if applicable; if not applicable, state NA):
(Maximum characters: 2000)
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How many students will you accept at one time? *
Up to how many students can you accept this year IF the need arises? *



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