MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_01C8B50D.B4606E40" This document is a Single File Web Page, also known as a Web Archive file. If you are seeing this message, your browser or editor doesn't support Web Archive files. Please download a browser that supports Web Archive, such as Windows® Internet Explorer®. ------=_NextPart_01C8B50D.B4606E40 Content-Location: file:///C:/AA24CAAD/Preceptor_form.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" PRECEPTOR ASSIGNMENT FORM

 

PRECEPTOR ASSIGNMENT FORM

FOURTH YEAR OFF-SITE CLERKSHIP

 

NAME

 =

 

SSN#

 

P.O. BOX #<= o:p>

 =

 

CLASS OF

 

PERIOD

 

DATES

 

COURSE NUMBER

 

COURSE TITLE

 

I NEED TO BE ASSIGNED TO AN AHEC SITE:       &nbs= p;            YES     =             &nb= sp;      NO

 

I HAVE COMMUTER STATUS AND NEED TO BE PLACED WITHIN ONE HOUR OF LEXINGTON:     YES       &nbs= p;   NO

 

 

Enter your top three choices for preceptor and location.

 

       &nbs= p; 1st Preference:   &= nbsp;    

 

Preceptor       &n= bsp;            = ;            &n= bsp;          

 

Town              =             &nb= sp;            =           

 

 

       &nbs= p; 2nd Preference:   &= nbsp;   

 

Preceptor              =             &nb= sp;            =     

 

Town              =             &nb= sp;            =           

 

 

       &nbs= p; 3rd Preference:   &= nbsp;    

 

Preceptor              =             &nb= sp;            =     

 

Town              =             &nb= sp;            =           

 

 

Preceptor Assignment - FOR COORDINATOR = USE ONLY

 

 

Period              =             &nb= sp;            =          

 

Physician              =             &nb= sp;            =      

 

Address              =             &nb= sp;            =        

 

 

Dates              =             &nb= sp;            =          

 

Phone #      &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;

 

City              =             &nb= sp;            =             

 

 

AHEC SITE:<= /span>        &nbs= p;            &= nbsp;    YES       &nbs= p;       NO

 

 

Coordinator= ’s Signature

 

 

 

 

   Date  =

 

Student: Return this form to t= he appropriate departmental contact person indicated on the preceptor list.

 

Coordinator: After preceptor a= ssignment is made, return this form to Beth Hartmann, MN 104 UKMC, 0298.

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