Preceptor Block Preference Form

Name*

First Last

Degree*

Email*

Practice Site Name:*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Phone (Please include extension in parenthesis):*

Alternate Phone:

Fax

During which blocks are you available to take a student (or students)?*

Block 1: 5/8/2023 - 6/18/2023

Can you Precept?*

Yes
No

If yes, how many students?

Block 2: 6/19/2023 - 7/30/2023

Can you Precept?*

Yes
No

If yes, how many students?

Block 3: 7/31/2023 - 9/10/2023

Can you Precept?*

Yes
No

If yes, how many students?

Block 4: 9/11/2023 - 10/22/2023

Can you Precept?*

Yes
No

If yes, how many students?

Block 5: 10/23/23 - 12/3/2023

Can you Precept?*

Yes
No

If yes, how many students?

Block 6: 12/4/2023 - 1/21/2024

Can you Precept?*

Yes
No

If yes, how many students?

Block 7: 1/22/2024 - 3/3/2024

Can you Precept?*

Yes
No

If yes, how many students?

Block 8: 3/4/2024 - 4/21/2024

Can you Precept?*

Yes
No

If yes, how many students?

Preceptor Block Preference Form