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: Click here to enter text. Click here to enter text. 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? Click here to enter text. Please list any special concerns or needs that you have for this preceptorship: Click here to enter text.