October Preceptorship Information Student Name: Preferred method of

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Please submit this completed form in the Clinical Preceptorship II D2L Drop Box
Return to: ATTN Dana Bailey, Academic Affairs
You are welcome to come to my office, call, email or text me at any time.
Telephone: 423-439-8003; or Cell: 423-557-3016; or Email: baileyd@etsu.edu
October Preceptorship Information
Longitudinal: Click here to enter text.
February Preceptorship: Click here to enter text.
Student Name: Click here to enter text.
Preferred method of
contact:
(Do you prefer to be
contacted by email,
telephone or text?)
Current Telephone
Number:
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Have you contacted a Preceptor for this course? Click here to enter text.
Preceptor Name:
Address:
Telephone:
Email:
Fax:
Office Contact:
How can I best help you at this time?
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Please list any special concerns or needs that you have for this preceptorship:
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