Preceptor Recommendation Questionnaire (Class of 2025)

Thank you for your referral for additional preceptors for the RVU PA Program! The Clinical Education Team will use this information to reach out to them. Please fill out as much information as you can about them and submit a new form for each potential preceptor. Contact Dr. Spilman at rspilman@rvu.edu if you have any questions. Thank you!

Submission Date

Your Name (last, first)

Your Email

Your Phone

Select One Option That Describes You

Preceptor Name (last name, first name)

Preceptor Degree

Field

Elective Type (if applicable)

Ortho, urology, dermatology, cardiology, etc.

Preceptor Email

Preceptor Phone

Preceptor Office/Hospital Name

Preceptor Clinic Address

{name}

How do you know them?

{name}

Anything else we need to know?

{name}

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