Nova Southeastern University, Inc
Health Professions Division, College of Allied Health & Nursing
Physician Assistant Department – Jacksonville, FL
APPLICATION FOR PRECEPTORSHIP
Preceptor Name: _______________________________________________________________________________________________
(Last )
(First)
(Check √)
Professional Data:
MD
DO
NP
PA
Florida Medical License Number: ______________________________________________ (Do not leave blank)
Board Certified: ____________ Board Eligible: ____________
Date Certified/Recertified: ____________
Medical / PA/ NP School: _______________________________________
Year Graduated ____________
Clinic/Practice Name: ___________________________________________________________________________________________
Street Address: ________________________________________________________________________________________________
City: _________________________________________ State: _______________________ Zip Code: ________________________
Telephone:
______________________________________
Facsimile: _________________________________________
Practice Contact:
______________________________________
Contact Phone: ______________________________________
Practice Website:
______________________________________
Email: _____________________________________________
Office/ Clinic Hours & Days: _____________________________________________________________________________________
*
The site prefers written-communication (reminders about upcoming students) by:
Fax
Email
Practice Specialty:

I can provide the following core rotation(s) for the Jacksonville Nova Southeastern Physician Assistant Students:
(Check √)

Family Practice
Prenatal Care & Gynecology
Emergency Medicine/ Urgent Care
Internal Medicine
Pediatrics
General Surgery
And/or I can offer the Physician Assistant Students the following elective rotation(s) or subspecialties of the above specialty:
(List all): _________________________________________________________________________________
Please check the primary type of practice:
(Check √)
Private Solo Practice
Private Group Practice
Hospital Clinic
Other type of Practice: _______________________________________________________________________
Is your practice facility a State or US Federally Designated:
(Check √)
: Rural Health Clinic
Rural Hospital
Community Health Center
Office of State Health Planning Department (OSHPD)
County of Public Health Agency
Federally Qualified Health Center (FQHC)
Other State, or Federally funded clinic or health facility (Describe: ___________________________________)
1.
2.
List the most common disease entities or problems for which you provide primary patient care:
________________________________
________________________________
_________________________________
________________________________
________________________________
_________________________________
________________________________
________________________________
_________________________________
Are Physician Assistants (PAs) and or Nurse Practitioners (NPs) currently employed at your practice?
If so, please specify: # of PAs _______________
Yes _____ No _____
# of NPs ________________
3.
What type of other office personnel/staff do you employ? ____________________________________________________________
4.
Do you presently hold a Clinical Faculty appointment with the Health Professions Division at Nova Southeastern University?
Yes _____ No _____
If yes, please specify the program: _____________________________________________________________________________
5.
Clinical Faculty Appointment Designation: ______________________________________________________________________
6.
How will the patient contacts and direct supervision be provided to the PA student?
_________________________________________________________________________________________________________
7.
Does your schedule allow for adequate instructional time and direct supervision of PA student? Yes _____ No _____
8.
How many rotation cycles ( each are 4 weeks) are you willing to participate in per year?___________________________________
9.
Specify which rotation(s) during the year you are able to accept student(or which cycles you cannot)(refer to Clinical Rotation
Schedule handout):_____________________________________________________________________________________
10. How many students per rotation slot are you able to accept? _________________________________________________________
11. Do other practitioners in your group want students assigned to them individually? Yes _____ No _____
*Please include the following: 1-CV, 2-Board/National
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*
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If not, will they participate in the clinical supervision and training of the student? Yes _____ No _____
If yes, Name: ____________________________ Telephone: ____________________ Certification, 3-State License, 4-Liability Insurance
12. Briefly describe any special demographic and/or ethnic population for which you provide services: _________________________
________________________________________________________________________________________________________
___________ % of practice for these special demographic or ethnic populations.
13. State the average number of outpatients you see per week (as an individual practitioner)?
____________________________
14. State the average number of inpatients you see per day in a:
Nursing Home: _______________
Hospital: ______________
15. Do you have one or more examination room (s) available to the student to see patients during the rotation?
Yes ____ No ____
16. Will the students be allowed to record their findings in the patients’ medical record? Yes _____ No _____
17. Do you have facilities for office laboratory and other diagnostic procedures? Yes _____ No _____
18. At what time, where, and to whom should the student report on the first day of the rotation? ______________________________
_______________________________________________________________________________________________________
19. Current Hospital Affiliations:
Hospital:
_____________________________________
Hospital:
_____________________________________
Address:
_____________________________________
Address:
_____________________________________
_____________________________________
_____________________________________
Administrator: _____________________________________
Administrator: _____________________________________
Telephone:
Telephone:
_____________________________________
_____________________________________
Additional Hospital Affiliations: _____________________________________________________________________________
20. Are you an employee with any of the hospitals listed? Yes _____ No _____
If yes, which ones? _______________________________________________________________________________________
21. Has your medical license ever been revoked, suspended or limited in any manner?
Yes ______
No ______
22 Have your hospital privileges ever been suspended, revoked, restricted or not renewed? Yes _____
No _____
23. Have you been party to a malpractice action during the past five years? Yes ______ No ______
24. Provide the full name of your malpractice carrier (if any): ___________________________________________________________
Specify malpractice amount: __________________________________________________________________________________
25. Additional Comments: ____________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Signature of Preceptor(s): __________________________________________________
Date: ________________________
Signature of Preceptor(s): __________________________________________________
Date: ________________________
Signature of Preceptor(s): __________________________________________________
Date: ________________________
IMPORTANT: Please attach a copy of each preceptor’s Curriculum Vitae, National/Board Certification, Current
License, and Insurance Certificate (if any). As an option, if you wish to become an adjunct faculty member, please
arrange for submission of your transcripts (requirement of Southern Association of Colleges and Schools).
Please FAX completed application to:
Mr. Randy Bennett, P.A. – Clinical Director, Phone: (904) 245-8981
Fax: (904) 245-8988
E-Mail: randbenn@nova.edu
OR
Please MAIL completed application to:
Mr. Randy Bennett, P.A. – Clinical Director, Phone: (904) 245-8981
Nova Southeastern University
Physician Assistant Program
6675 Corporate Center Parkway, Suite 112
Jacksonville, Florida 32216-8080