Preceptor Information

Ambulatory Community Selective

The University of Texas Medical Branch
Galveston, Texas

Dear Dr. _________________

_________________, a fourth year medical student at the University of Texas Medical Branch has requested permission
to have you serve as a preceptor. We are requesting some basic information so that we might add you to our list of
approved preceptors. We would appreciate your taking the time to provide the information listed below.

Your Name: _________________________________ Clinic/Site Name: ______________________________________

Office Address: _________________________ ________________________, Texas _________

Street City Zip

Office Phone # __________________________ Office Fax # _____________________________

Clinic Website: __________________________________________________________________

Email Address: _________________________________________________________________

Medical School Attended: ____________________________________Graduation Year: _______

Site of Residency 1: ________________________________________Discipline ______________

Dates of Residency 1:_________ to ________

Site of Residency 2: ________________________________________ Discipline ______________

Dates of Residency 2:_________ to ________

Did you complete an approved residency program: [ ] Yes [ ] No

Please indicate your practice discipline: ________________________________________________

Are you board certified in you practice discipline: [ ] Yes [ ] No

Date of certification or most recent re-certification: ______/____/______.

Month Day Year
How long have you been practicing at your current site: ______ years.

What type of practice do you have? [ ] Solo [ ] Group [ ] Multispecialty

Do you use a physician extender (nurse practitioner or physician assistant)? [ ] Yes [ ] No

Have you agreed to take the above named student: [ ] Yes [ ] No

Thank you for taking the time to provide this information. The student will bring with him/her an evaluation form that you
should fill out at the conclusion of the preceptorship. You will also be sent a course syllabus which states the curriculum
goals and objectives. If you have any questions or concerns about the student’s performance during the Selective, please
do not hesitate to call.

Please mail, e-mail or fax this form to the following address:

Brian Sullivan, Office of Clinical Education, University of Texas Medical Branch
301 University Blvd., Galveston, Texas 77555-0413.
(Office) 409-747-0265 (Fax) 409-772-6565 (E-mail) brian.sullivan@utmb.edu