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Add ____ Date ____________ Update____ Preceptor #_______ Delete ____ Course # _________ |
VOLUNTEER FACULTY (PRECEPTOR) INFORMATION FORM (PIF)
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Upon completion of this form and approval of the respective Center for Osteopathic Regional Education (CORE) Assistant Dean you may be granted a one year temporary Volunteer Faculty appointment through Ohio University College of Osteopathic Medicine's (OU-COM) Office of Academic Affairs. Volunteer Faculty appointments are granted to individuals teaching OU-COM students either on a limited basis or as a new preceptor. Volunteer Faculty who actively participate in the education of OU-COM medical students may apply for a CORE Clinical Faculty or CORE interdisciplinary Faculty appointment. Contact the CORE office in your area for more information. Recommend you complete and send with this application the “New Preceptor Information” readings found on our faculty development web site at http://www.oucom.ohiou.edu/fd/newpreceptor.htm.
Please complete all sections that pertain to your professional position.
Name______________________________________________Degree____________ Professional#/Yr. Grad.________________
Corporation Name (If Applicable) ____________________________________________________________________________
Office Address______________________________________________________________________________________________
___________________________________________________________________________________________________________
_______________________ ______ _________________________ _____________ ( ______)__________
City State County Zip Code Phone
Specify Type of Practice: (Check all that apply) Indicate Percentages of Practice:
___ Solo, Private Practice ___ HMO ___ % Medicaid
___ Group, Private Practice ___ Hospital ___ % Medicare
___ Partnership ___ Office ___ % Private/Commercial
___ Corporation ___ Other ________ ___ % Charity
___ % Other _____________
Specify Practice Location: Specify Patient/Client Volume:
___ Small Community ___ Inner City ___ < 25/day ___ 50-75/day
___ Rural ___ Suburban ___ Urban ___ 25-50/day ___ > 75/day
Indicate your primary area of practice (i.e. cardiology, Family Medicine, General Surgery, OB/Gyn, Podiatry, Etc.)
_______________________________________________________________________________________________________
Indicate secondary area of practice: _______________________________________________________________________
Specify percent of Osteopathic Manipulative Medicine in practice:_____________________________________________
Please list other physicians/practitioners affiliated with your practice who teach OU-COM students:
_________________________________________________________________________________________________________
Name Professional #/Year Graduated
_________________________________________________________________________________________________________
Name Professional #/Year Graduated
List anyone other than yourself who should be notified of a student’s rotation (e.g. Med. Ed. Dept.):
Name/Tile ______________________________________________________ Phone (_______)__________________
Address __________________________________________________________________________________________________
Briefly describe how this rotation will benefit the student:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
VOLUNTEER FACULTY (PRECEPTOR) INFORMATION FORM (PIF)
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Please note: Information on this page will be maintained in a confidential file at Ohio University College of Osteopathic Medicine and/or the nearest CORE office.
Prof. Organization # (i.e., AOA, AMA, ABA, ADA, etc.) ________________________________________________________
Professional College: _______________________________________________________________________________________
Internship: Program Name______________________________________ Institution ________________________________
Residency: Program specialty ___________________________________ Institution ________________________________
SS/Tax ID# _________________________________________ Ohio License # ____________________________________
(necessary for database-kept confidential)
DEA # ____________________________________________________________________________________________________
Other State(s) Where Currently Licensed/Practicing _____________________________________________________________
Identify Malpractice Carrier _________________________________________________________________________________
Specify Level of Coverage ___________________________________________________________________________________
Indicate whether you have ever been convicted of a felony. ____No ____ Yes
If yes, please explain:
Indicate whether your license to practice medicine has ever been revoked or suspended. ____No ____ Yes
If yes, please explain:
OPTIONAL tc "OPTIONAL " \l 2Sex: M____ F____ Ethnicity:____ White (non Hispanic) ____ HispanicMarital Status: Married ____ Single ____ ____ Black ____ Native American____ Asian/Pacific IslanderSpouses Name:________________________________________tc " Spouses Name\:________________________________________" |
Physicians Signature ____________________________________________________ Date _________________________