North East Pennsylvania Area Health Education Center

Enhancing access to health care through education

AHEC Preceptors Interest Form

To support the community-based training of primary care health profession students, the Northeast PA AHEC seeks to identify healthcare professionals who would consider precepting students. We are interested in working with those who would like to offer experiences to students, expand their role with students, and/or who would like the help of the AHEC with students they already host. The AHEC can offer preceptor educational support, help with student housing, and act as an intermediary with the health science institution sending the student. There is no cost to the preceptor, and all students are scheduled subject to the preceptor's desired schedule, with a suggested minimum of one student per year. If you are interested in participating in this process, please complete the form below, and our office will contact you. Thank you for your interest.

1. NAME: Title Last Name First Name Initial

Discipline (MD, DO, PA-C, CRNP, LCSW, etc.)

Email (Required for online submission)

Teaching affiliation (schools):

Race/ethnicity?

2. SITE:

Site Name

Street Address City State Zip Code

Telephone

What percent of the patients at this site are minority patients?

What percent of the patients at this site are Medicaid patients?

Type of providers and type that are providing service at this site (ie, nurse20, physician5, physical therapist2 etc.

3. BOARD CERTIFICATION:

4. Do you currently precept students?

If yes, from which fields?

If Other (please specify):

5. If you hold a current faculty appointment at a Health Science Institution, please complete the following:

Name of Institution:

Academic Title:

6. Does your practice site hold any designation for providing care to the underserved, e.g. Rural Health Center, Community Health Center (CHC), or does a significant percentage of revenue come from Medicaid?
Please specify:

7. Please specify anything else about the practice that might provide particularly interesting student experiences. (patient mix, very rural, etc.)

Enter the below form code (all numbers)

 

Eastcentral - Northeast Pennsylvania Area Health Education Center
5662 Interchange Road Lehighton, PA 18235 | Phone: 610.379.2001 | Fax: 610.379.2005 | ecneahec.org