HEALTH PROFESSIONS DEPARTMENT Physician Assistant Studies

This form can also be completed online at: http://tinyurl.com/y8d9lj9x Date: To: From: Subject: (Preceptor) (Site Name) Troy K. Bender, Northeastern State University Physician Assistant Program Required Physician Assistant Student Assignments Thank you for your response to our call for preceptors. We appreciate your support of this vital program. This Program Letter of Agreement (PLA) serves as an agreement between Northeastern State University s Physician Assistant Program and the Participating Site's Preceptor(s) who desires to provide clinical education to NSU physician assistant students. This PLA is effective for one year and will automatically renew annually unless updated, changed or terminated sooner in writing by the Physician Assistant Studies Program, the Participating Site or the individual preceptor. I, (Preceptor name), agree to serve as a Preceptor for NSU PA students. I acknowledge that NSU s Program Director, NSU s Medical Director and me, the Preceptor are responsible for the clinical education and supervision of NSU PA students at the Participating Site. The NSU Director of Clinical Education and Director of Admissions may also direct the PA student s clinical education at the Participating Site. As a Preceptor, I agree to provide appropriate supervision of physician assistant students in patient care activities and maintain a learning environment conducive to the clinical education of the physician assistant students. During each rotation or similar education assignment, the Preceptor agrees to evaluate student performance in accordance with program requirements and policies and agrees to accurately complete and return student evaluation forms to the Program within two (2) weeks of completing the clinical rotation assignment. Via email, NSU will provide each Preceptor clinical education information specifying: 1. Duration of the educational experience. 2. Learning objectives, content of course, and description of education experiences. 3. Preceptor responsibilities for teaching, supervision of patient care, and evaluation of physician assistant students. In cooperation with the Program Director, the Site Director, and the Preceptor(s), the Participating Site is responsible for the day-to-day activities of the physician assistant students to ensure that the outlined goals and objectives will be fulfilled during the course of the clinical educational experiences at the Participating Site. During assignments at the Participating Site, PA students may also have required program assignments that they must attend, such as: advanced clinical days, academic afternoons, core conferences, grand rounds, and other scholarly activities. PA students receiving clinical education at the Participating Site will be under the general supervision of the NSU Physician Assistant Studies Program, the Physician Assistant Studies Program s Policy and Procedure Manual and the Participating Site s policies for physician assistant students and graduate medical education. HEALTH PROFESSIONS DEPARTMENT Physician Assistant Studies 2400 W. Shawnee St. Muskogee, Oklahoma 74401-2275 P 918.444.5464 F 918.444.5411 www.nsuok.edu/physicianassistant

The Participating Site shall provide appropriate clinical education, adequate parking and workspace, and shall take reasonable steps to ensure the safety of the physician assistant students during assignments. Please sign and return to: Northeastern State University Physician Assistant Studies Program PO Box 549 Muskogee, OK 74402-0549 If you d prefer, you can fax to 918-444-5411 or email to paprogram@nsuok.edu Thank you again for your support. Participating Site/Preceptor (Preceptor) Email Date Physician Assistant Studies Program Mr. Troy K. Bender, MPAS, PA-C Physician Assistant Studies Program Director Northeastern State University Date

INTEREST FORM This form can also be completed online at: h p:// nyurl.com/y8d9lj9x The Northeastern State University Physician Assistant Studies Program is planning now for the supervised clinical prac ce experiences vital to the educa on of PA students. The experience and opportuni es that you, as a prac cing clinician, can bring to this program as a preceptor will be invaluable to the success of the program. Rota ons will begin in August 2020. We need your response now for accredita on purposes and to assure coverage in all areas. Name: Date: Degree Cer fying Board: Exp. Date. If PA/NP, Sup./Coll. Physician Name: Sup/Coll. Physician Board Specialty: Exp Date. Prac ce Name: Specialty: Prac ce Loca on: Prac ce Contact Person/Title: Contact s Phone Number Fax Number: Prac ce or Personal Email: Do you have hospital privileges? Y N Name of Facility Yes, my prac ce is willing to func on as a Clinical Preceptor Site. Number of rota ons willing to precept annually (rota ons are 4 weeks each) Number of students per year (one student per rota on) Yes, I was given a copy of Clinical Rota on Expecta ons (a ached) Prac ce Se ng: (check all that apply) Outpa ent Inpa ent Long-Term Care Opera ng Room Emergency Department Urgent Care Clinical Discipline: (check all that apply) Family Prac ce Internal Medicine Pediatrics Behavioral & Mental Health Women s Health Surgery Emergency Medicine Other (please describe) I am also interested in contribu ng to the Northeastern State University Physician Assistant Studies Program in each of the following manners: (please check all that apply) Clinical Lectures for Didac c Educa on Medical Topic(s) of interest: Serve as Advisor to the Program Advisory Commi ee Adjunct Faculty for Didac c/clinical Educa on Please Sign: Thank you for your support of the NSU Physician Assistant Studies Program! Please return completed form to: Northeastern State University Director of Clinical Educa on Physician Assistant Studies Program 2400 West Shawnee St. Muskogee, OK 74401-2275 mdb 2/1/2018

This form can also be completed online at: h p:// nyurl.com/y8d9lj9x Clinical Rota on Expecta ons Supervised Clinical Prac ce Experiences (SCPEs) are vital to the educa on of Physician Assistant students. They provide meaningful direct student pa ent care experiences working in a variety of clinical prac ce environments. This allows students an opportunity to apply and enhance the vast knowledge and skills they have accrued during the didac c phase of the program while con nuing to gain new knowledge and skills in a professional clinical se ng. We want this experience to be both educa onal and interes ng. Therefore, there are expecta ons and responsibili es of three key par es involved in the SCPEs as outlined below. Preceptor Responsibili es 1. To orient the student at the onset of the rota on with respect to policies and procedures at all clinical sites where students will accompany the preceptor and with which students are expected to comply. 2. To review with the student the expecta ons and objec ves for the rota on in an effort to develop a strategic plan for a ainment of these. 3. To provide ongoing and mely feedback regarding clinical performance, knowledge base, and cri cal thinking skills to the student throughout the rota on. 4. To provide mely submissions of mid-rota on and end-of-rota on evalua ons to the Program regarding the student s progress. 5. To provide the student with an appropriate clinical environment and a variety of pa ent encounters which enable the student to meet the Program s stated objec ves. 6. To supervise, demonstrate, teach, and observe clinical ac vi es in order to aid in the development of clinical skills and ensure proper pa ent care. 7. To delegate to the student increasing levels of responsibility for clinical assessment and management as appropriate to the student s experience and exper se. 8. To recognize that the student is on a learner status and to ensure that the student does not render care beyond the realm of educa onal value and as permi ed by professional standards. 9. To par cipate in the evalua on of clinical skills and medical knowledge base through the following mechanisms: a. Direct supervision, observa on, and teaching in the clinical se ng. b. Direct evalua on of presenta ons (including oral and wri en). 10. Assignment of outside readings and research to promote further learning. To review and cosign all student documenta on and char ng. If a student is unable to directly document on the pa ent s chart or enter data in the EHR, preceptors should require the student to write their own note on plain paper and review it for accuracy and appropriateness. 11. To allow me for teaching ac vi es such as teaching rounds, chart review periods, reading assignments, and recommending a endance at mee ngs or conferences (grand rounds etc). mdb 2/1/2018

This form can also be completed online at: h p:// nyurl.com/y8d9lj9x 12. To be a model to the student in terms of professional behavior and ethics and expose the student to, and teach in accordance with, current prac ce guidelines and accepted standards of care. To dialogue with faculty during site visits to evaluate student progress and assist in the learning process. 13. To maintain license and cer fica on as required by the state of Oklahoma to prac ce the preceptor s professions and to report immediately to the Program and changes in staff status, affilia on, sanc ons, loss of license or cer fica on, or any change reportable to the Na- onal Provider Databank. 14. To inform the Director of Clinical Educa on if he or she will be taking a vaca on of one week or greater while supervising a student 15. To provide emergency medical care to students in the event of injury or illness (but the preceptor shall not be responsible for the cost of such care). Program Responsibili es 1. To prepare students academically and clinically for the clinical phase of their educa on. 2. To ensure that criminal background and sex offender checks and drug screens are completed by all students prior to the start of the clinical year at a cost incurred by the student. 3. To provide and ensure that each student has completed training in OSHA and HIPAA prior to the start of the clinical year. 4. To provide instruc on regarding the risk of exposure and repor ng procedures should exposure occur. 5. To iden fy quality clinical rota on sites and preceptors dedicated to providing an op mal clinical educa on. 6. To maintain all affilia on agreement (PLA or MOU) with all clinical sites and preceptors. 7. To orient Preceptors and students to the policies and procedures of the clinical year. 8. To ensure that all students have current malprac ce liability insurance as well as current health insurance and up-to-date immuniza ons. 9. To ensure that all students maintain current BLS and ACLS cer fica on prior to the start of the clinical phase of the program. 10. To forward to preceptor in a mely manner informa on regarding number of students scheduled for rota on including rota on beginning/end dates and any documenta on they may require. 11. To provide each preceptor a copy of the clinical educa on handbook with a list of all policies. 12. To provide each preceptor a copy of the clinical rota on syllabi for their par cular rota on. 13. To inform the Preceptor of rota on objec ves and supply student evalua on materials. 14. To review all component used for the evalua on of clinical rota on and maintain responsibility for the assignment of the final grade for each student for all clinical rota ons. 15. To maintain open and easily accessible lines of communica on between preceptor and program faculty in an a empt to an cipate problems before they arise. 16. To respond to ques ons and/or concerns from the Preceptor or student in a mely manner. mdb 2/1/2018

This form can also be completed online at: h p:// nyurl.com/y8d9lj9x Student Responsibili es 1. To comply with all site-specific requirements and policies regarding all clinical sites the preceptor works in. 2. To maintain open communica on with the preceptor to elicit and accept feedback regarding clinical performance including strengths and weaknesses. 3. To successfully complete the requirements of the rota on outlines in the course syllabus. 4. As it is not possible nor expected that the student will be exposed to all disorders listed on the syllabus while on rota ons it is expected that the student take responsibility for his or her own learning by studying about all disorders on the syllabus on their own me. 5. To act professionally in the clinical se ng including wearing proper iden fica on, complying with dress code standards, and conduc ng oneself with a professional and ethical demeanor at all mes. 6. To report to the clinical site on me and fully prepared to work with all necessary equipment. 7. To meet with the preceptor at the beginning and throughout the clinical rota on to discuss mutual goals and expecta ons. 8. To always iden fy oneself properly as an NSU PA student. 9. To always ask for permission from the pa ent to par cipate in their care. 10. To be aware of one s limita ons as a student as well as the limita ons and regula ons pertaining to PA prac ce. 11. To always work under the direct supervision of a preceptor. 12. To never func on as an employee of a clinical site or assume primary responsibility for a pa ent s care. 13. To contact the Program immediately with any ques ons regarding the student s role and to report immediately if the student does not have direct supervision. Students shall not treat and discharge a pa ent from care without the pa ent being seen by the clinical preceptor. 14. To follow the work hour guidelines put forth by the program. The student is expected to work nights, weekends, and be on-call if required by the preceptor. 15. To a end and par cipate in all Program required ac vi es including seminars and end of rota on examina ons. 16. To report any and all exposure to blood or bodily fluid and to follow the NSU exposure protocol. 17. To provide the program with current and accurate contact informa on to include phone numbers and email address. mdb 2/1/2018