IAFP FOUNDATION 2008 SUMMER EXTERNSHIP PROGRAM

                                     PRECEPTOR PARTICIPATION FORM  

Preceptor Name:                                                                                                                               

Clinic Name:                                                                                                                                     

Office Address:                                                                                                                                  

City/State/Zip:                                                                                                                                  

Phone Number:                                                                     Fax #:                                                

E-mail Address:                                                                                                                                 

 1.         Please indicate your availability in hosting a medical student:

            a)  I can host a maximum of         student(s) during the summer of 2008
b)  I can host students between                     and                      (give dates). 
c) I can host a medical student at any time EXCEPT as noted:                                                                                                                                                                                      

 2.         Are you able to provide room and board for a student, either through personal means or
              through your hospital?         Yes                              No

            If yes, please explain arrangements and any restrictions:                                                                                                                                                                                                                                                                                                                                                         

3.         Would your site benefit by having a student who is fluent in a foreign language?             Yes                No

            If yes, please indicate which language:                                                         

  4.         Will your extern be exposed to:

                        Sub-specialists to whom you refer patients?                      Yes        No 

                        Mid-level providers (PAs/NPs/etc.)?                                Yes        No

                        Nursing home and/or hospice personnel?                          Yes        No

                        Obstetrics/deliveries?                                                     Yes        No 

                        Geriatrics?                                                                    Yes        No 

 5.         Who is your malpractice insurance carrier?                                                                  

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As a preceptor for the IAFP Foundation Summer Externship Program, I agree to assume responsibility for the work schedule of the student(s) assigned to my site.

Signature                                                                                Date

Preceptors will be notified by April 30th of the student assignments and externship dates.  Questions???  Contact Crishelle at 630-435-0356 ext. 211 or via e-mail at corourke@iafp.com.

Please return this application to:  Illinois Academy of Family Physicians Foundation, Summer Externship Program, 4756 Main Street, Lisle, Ill. 60532, or fax: 515-987-8980.