Preceptorship Lottery Request Form

Please complete the form. Students graduating during the current academic year will be given first priority.

Student Information
Name*
First Last
Email*
Anticipated Graduation Date*
MM slash DD slash YYYY
Program

For dual degree students, Please provide both degrees (e.g. ND/MSOM or MScN/MScGH).
Term*
Availability
Please enter the times your are available for each of the fields below. Please leave the field blank if you are unavailable on that day.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preceptor History
Total Preceptor Hours*
Enter the total number of preceptor hours you have earned toward your degree.
Work History*
Have you worked, or are currently working with any preceptor lottery doctors?
- Yes
- No
Hours per Lottery Physician*
Please use the fields below to list the physician's name and the total hours you worked under this physician. If you have worked for more then one physician, you may add additional fields by clicking the plus (+) icon located adjacent to the visible group of fields.
Physician's Name Hours worked
Scheduling Options
Refer to the Preceptor Lottery Schedule, available on Moodle under Clinic Resources/Clinic Schedules, when completing the fields below. Only requests for physicians from the lottery schedule, taking note of their location and availability, will be considered.
Preferred Shifts*
Enter the name of the physician and the shift you are interested in working from the lottery schedule. (List physician name and preferred shift). Additional shifts may be added by clicking the plus (+) icon located adjacent to the visible group of fields
Physician's Name Shift
Willing to Commute*
Are you willing to commute 10+ miles from campus to work with a preceptor lottery doctor?
- Yes
- No
Policy*
Once you have accepted a placement with a preceptor, you are under a professional obligation to attend that rotation. If you develop a conflict with the timing of that preceptorship, you may swap with another eligible student no later than two weeks prior to the start of the rotation. Cancellations or switches after that date are subject to 10 docked preceptor hours and a referral to the Honor Council for unprofessional conduct.
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Preceptorships

Student Information

Availability

Preceptor History

Scheduling Options

Program Contacts

Physician's Name	Hours worked

Physician's Name	Shift