Preceptor Letter of Intent - 2023-2024 Header Image

Welcome to Morehouse School of Medicine Department of Physician Assistant Studies. Complete the form below providing your true availability and student capacity. Clerkship assignments are made with consideration to course requirements, specialty interests, and individual progression to ensure student success. Please communicate with the Clinical Curriculum Manager should there be any change to your stated availability. Thank You for your continued support.

*Clerkship assignments are tentative and subject to change.

Preceptor Letter of Intent

Clinical Year Availability

I am interested in providing supervised clinical practice (SCP) for students enrolled in the Morehouse School of Medicine Physician Assistant Program. I would like additional information about the program and how to become a clinical preceptor. I understand that this is a preliminary request to identify potential sites for clinical practice experiences.

Name*

First Name

Last Name

PA-C MD DO

Other:

Phone*

Email*

If Applicable, Name of Supervising Physician:

Practice Specialty:*

Name of Clinical Site:*

Clinical Site Mailing Address:*

Address Line 1

Address Line 2

City

State

ZIP Code

Practice Setting(s):*

Outpatient Inpatient Emergency Department Operating Room

Affiliated Hospitals

For the purposes of student credentialing

Patient Demographics:*

Infants-Adolescents Adults Seniors Prenatal/Women’s Health

Have You Ever Taught Students in the Clinical Setting?*

Yes No

Are You Interested in Guest Lecturing?*

Yes No

Have you been recruited to become a PALS preceptor?

Yes, I have been in contact with a PALS representative No, but I am interested in the extended benefits of becoming a P.A.L.S. preceptor No, I am not interested

Georgia, N. Carolina, S. Carolina, Florida, Alabama ONLY

How many students can you precept per SCPE (rotation)?*

Signature*

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Use your mouse or finger to draw your signature above

Date

KNOWLEDGE • WISDOM • EXCELLENCE • SERVICE
720 Westview Drive, SW Atlanta, GA 30310 Telephone: (404) 756-1254 Email: pas@msm.edu