Preceptor Application

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone Number *

Medical Licensure Type *

DO
MD
PA*
NP*

Primary Specialty*

Board Certified? *

Yes
No

Certifying Board *

State License Number *

Issuing State *

Professional School Name *

Year Graduated *

Name of Practice/Facility *

Hospital Affiliations *

Primary Person of Contact (if different than Preceptor) *

First

Last

Email

Phone

Preferred Method of Communications

Email
Phone

Practice Type *

Inpatient
Outpatient
Emergency Room

Patient Demographics *

Services Rendered *

Clerkship

A clerkship rotation is a 4-8 week period of time (depending on the specialty field) in the 3rd and 4th year of medical school, during which a student gains clinical education, experience and mentorship in working with licensed physicians and other independent health care providers. The medical school will provide reading/course materials, evaluation tools and other academic support, including a 24 hour help line. The medical students will be covered by liability and health insurance. Clinical preceptors will receive faculty appointments, CME credit and honoraria for their time and expertise on a per student/per month basis.

How many students per rotations are you willing to accept? *

How many students per year are you willing to accept? *

Are there any months you are not able to accept students? *

On average, how many patients do you see per week? *

Comment or Message *

Additional Information

Has your license to practice medicine in any jurisdiction ever been refused, limited, suspended, or revoked? *

Yes
No

Have your privileges on any hospital staff ever been refused, limited, suspended, revoked, diminish or non-renewed? *

Yes
No

Has your DEA registration or State controlled substance certificate ever been limited or suspended or revoked? *

Yes
No

Have you ever been convicted of a misdemeanor or a felony (other than a minor traffic violation)? *

Yes
No

If you answered YES to any of the questions above, please provide a written explanation below.

CONSENT

I agree

I hereby certify that the information on this application and all other information that I receive otherwise provided is true and correct. I understand that any misrepresentation or omission will be sufficient cause for cancellation of this application or removal from the clinical faculty roster.

I Agree to notify the Saint Padre Pio Institute for the Relief of Suffering School of Osteopathic Medicine credentialing department of any changes to my license or employment status.

Religion

Mandatum

I agree

The Saint Padre Pio Institute for the Relief of Suffering, School of Osteopathic Medicine is a Catholic institution, under the Archdiocese of Kansas City in Kansas and adherent to Ex Corde Ecclesiae. As preceptor faculty, it is intended that you shall qualify as a “religious minister” under the First Amendment to the U.S. Constitution to the maximum extent of the law as contemplated by applicable Supreme Court precedent, including Hosanna-Tabor Evangelical Lutheran Church & School v. EEOC, its progeny, and state law-equivalents. As preceptor faculty, you acknowledge and accept the following:

1. You will sign and maintain a mandatum of fealty to the bioethical and other principles of the Catholic Church in all teaching and interactions with medical students. (attached/link)

2. You will not participate in the provision of care that is in contradiction to the bioethical principles of the Catholic Church, including, but not limited to: elective abortion, provision of abortifacient contraception, euthanasia and/or withholding of basic, ordinary care for the purpose of hastening death, gender reassignment or transition care, including surgery and hormonal therapy.

3. In your hospital and clinic practice, you will similarly indemnify and protect medical students in your charge from any requirement by others to provide care in contradiction to Catholic bioethical principles, as described in #2, above and that any such refusal to participate in such care shall not adversely affect the medical students’ academic evaluation, progress or participation in other patient care activities.

4. You will abide by the Code of Conduct of the Saint Padre Pio Institute for the Relief of Suffering, School of Osteopathic Medicine.

Clerkship

Additional Information

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