Student Applicant s Name: preceptor profile UNIVERSITY OF NORTH DAKOTA PHYSICIAN ASSISTANT PROGRAM School of Medicine and Health Sciences, Department of Physician Assistant Studies PERSONAL DATA 501 North Columbia - Road Stop 9037 Grand Forks, North Dakota 58202-9037 Phone (701)777-2344 Toll Free: (866) 431-2087 Fax (701)777-2491 email: und.med.paprogram@med.und.edu Name: (Please Check ) MD DO PA Practice Specialty: Family Medicine Primary Care Other Clinic/Office Name: Address: Street City State Zip Code Office Phone: ( ) - Fax: ( ) - E-mail address: Home Phone (optional): ( ) - Board Certification Specialty & Date: License Number: State of Issue: Expiration Date: Please attach current CV. Must include the following information: Education and Training: Pre-Medical, Medical, Internship, Residence, Physician Assistant Board Certifications Participation in CME activities for the past 2 years S:\General\Web Material\July 2014-Present (Rhapsody)\preceptor-profile-revised-1_16.docx 1
How do you describe your practice? Special practice interests (e.g. C-V diseases, pediatrics trauma, etc.) Do you use any alternative healing methods? Yes No If so, please list methods here: Total number of clinics in which you see patients: Total number of nursing homes in which you routinely see patients: Total number of hospitals in which you routinely see patients: Approximate the percentage of patients you see for each of the following categories: (total should equal 100%) % Episodic acute problems % Chronic diseases % Routine physical exams % GYN-Family Planning % Obstetrics % Mental Health % Other significant areas* *Please describe: Approximate the percentage of patients you see by age % Pediatrics (Newborn to 10 years) % Adolescents (11-18 yrs). % Adult (19-64 yrs) % Geriatrics (65 yrs and older). Approximate the percentage of patients you see by gender % Male % Female Patient Numbers and Work Hours: Total number of years you ve been in practice: Total number of years at present location: State the average number of outpatients you see PER DAY: (as an individual practitioner) State the average number of inpatients you see per day in a: hospital Nursing Home Indicate the number of hours per week that you work in the following areas: Office /Clinic hours/week Hospital hours/week Nursing Homes hours/week ER hours/week Urgent Care hours/week Administrative duties hours/week Total hours per week you work S:\General\Web Material\July 2014-Present (Rhapsody)\preceptor-profile-revised-1_16.docx 2
Practice Organization (check appropriate space): Solo practice (fee-for-service) Partnership (fee-for-service) Single Specialty Group (fee-for-service) Multiple Specialty Group (fee-for-service) Single Specialty Group (pre-paid) Multiple Specialty Group (pre-paid) Hospital Clinic Military Other type of practice: If you are an employee of a corporation or if you share in ownership of your practice, is the administrative head of the organization (or your partners in the practice) aware of and in agreement with your precepting a physician assistant student? Practice Site Information: Yes No (please explain) Not applicable, I have my own practice. Is your practice located in a Federally Designated Medically Underserved Area? Yes No Unknown Is your practice site a US Federally Designated: Community Health Center FQHC (Federally Qualified Health Center) Homeless Health Care site Public Housing Primary Care Program Rural Health Clinic Indian Program: Tribally Run Health Program Indian Health Service Site Urban Indian Health Center Migrant Health Center/National Center for Farmworker Health Other federally designated or funded clinic or health site (Describe ) Is your practice site a State Designated or State Funded clinic? Yes No Clinical teaching/supervisory activities: Please check all that apply Clinical preceptor for UND PA student: Name: Clinical preceptor for other PA or NP Students Clinical supervisor for medical students Supervisor for practicing PA s or NP s Current clinical teaching Names of other preceptor(s) who would assist in supervising this student: 1. S:\General\Web Material\July 2014-Present (Rhapsody)\preceptor-profile-revised-1_16.docx 3
2. Community Characteristics: Approximate population of city/town in which the clinic is located: Total population of area served by medical practice: Number of practicing medical providers: In the city/town: Racial/ethnic makeup of population served: Major industries/occupations: Practice Facility & Personnel: 1. Please indicate the number of examining rooms that are available to you on the days this student will be in the office. Rooms: 2. Does the facility have an office: a. laboratory Yes No b. X-ray Yes No c. Procedure room Yes No 3. How many medical providers in your clinic? MD s DO s PA s NP s Other 4. Within this practice site, students would be able to evaluate patients in which of the following clinical settings? (check all that would apply) Emergency Dept. Inpatient Operating Room Outpatient 5. Within this practice site, which of the following clinical rotations are available for the student? Behavorial/Mental Health Emergency Medicine Family Medicine General Surgery Internal Medicine Ob/Gyn Pediatrics Insurance Information: 1. Has your medical license ever been revoked, suspended or limited in any manner? Yes No 2. Have you been party to a malpractice action during the past five years? Yes No 3. Have your hospital privileges ever been suspended, revoked, restricted, or not renewed? Yes No 4. Provide the full name of your malpractice insurance carrier: *If you answered YES to any of the questions above, an explanation must be submitted with this application. An affirmative answer to any of these questions will not automatically preclude this application from being processed. NOTE: UND Students are covered by the University of North Dakota professional liability. S:\General\Web Material\July 2014-Present (Rhapsody)\preceptor-profile-revised-1_16.docx 4
Additional Information: 1. How long have you known the student/applicant? 2. What, if any, is your professional relationship with the student/applicant? Please describe: 3. If you are planning to be a Primary preceptor for the student, you would be principally responsible for his/her clinical education. Students are expected to complete 32 hours per week clinical practice time for a total of 35 weeks over a period of one year. Do you feel you will be able to devote this amount of time to the student s education? Yes No 4. Is there a possibility of hiring this student after graduation within: a. Your practice: Yes No Unknown b. Your health care system: NA Yes No Unknown I agree to serve as the primary preceptor and provide one-to-one clinical teaching, supervision, and evaluation feedback for PA Program applicant during the clinical times of Phase I, II, and III. Student I will supervise: Preceptor Name Preceptor Signature Date Optional Data Completion of this information is voluntary and does not affect the status of your application. However, you are urged to complete this section because this information is frequently requested by state and federal agencies and professional organizations for statistical purposes and can affect our ability to obtain state/federal funding. Please check the appropriate boxes: Gender: Male Female How do you describe yourself? (please check all that apply) American Indian/Alaska Native Asian Indian Black/African American Chinese Cuban Filipino Japanese Korean Mexican/Mexican American/Chicano Native Hawaiian Other Asian Other Pacific Islander Other Spanish/Hispanic/Latino Puerto Rican Samoan White (Non-Hispanic) No Answer Other Please place in a sealed envelope and return to applicant. UND is an equal opportunity/affirmative action institution. For additional information on equal opportunity policies and procedures, see UND catalogues and WEB Site:ww.med.und.nodak.edu/physicianassistant S:\General\Web Material\July 2014-Present (Rhapsody)\preceptor-profile-revised-1_16.docx 5