Physician's Assistant Program - Preceptor - Site Assessment Form

Macon & Joan Brock Virginia Health Sciences at Old Dominion University Eastern Virginia Medical School

Preceptor Information
Date completed Date completed / MM / DD YYYY
Name Name * First Last
License number *
State *
Credentials *
Board certified *

Board certified Yes No
Area of certification *

i.e. specialty
NCCPA # (if a PA ). If not a PA, enter N/A. *
Number of years practicing in your area of certification? *
Are you an EVMS/ODU PA Alum?

Are you an EVMS/ODU PA Alum? Yes No
If yes, what year did you graduate?
I attest that I have read and understand the preceptor handbook, preceptor quick reference guide, student learning outcomes, rotation syllabus, preceptor orientation checklist, and quick reference video. *

I attest that I have read and understand the preceptor handbook, preceptor quick reference guide, student learning outcomes, rotation syllabus, preceptor orientation checklist, and quick reference video. Yes No
I attest that I am aware of my responsibilities, including but not limited to: Providing a safe and appropriate learning environment for PA students. Reviewing and abiding by all policies and procedures outlined in the orientation materials. Communicating regularly with the program regarding student progress and any concerns. *

I attest that I am aware of my responsibilities, including but not limited to: Providing a safe and appropriate learning environment for PA students. Reviewing and abiding by all policies and procedures outlined in the orientation materials. Communicating regularly with the program regarding student progress and any concerns. Yes No
I agree to uphold the standards, guidelines, and expectations outlined in the above documents. I understand that failure to comply may result in the revocation of my preceptor status. *

I agree to uphold the standards, guidelines, and expectations outlined in the above documents. I understand that failure to comply may result in the revocation of my preceptor status. Yes No
Email address *
Phone number Phone number - ### - ### ####
Preferred method of contact

Preferred method of contact Email Phone
Practice Information
Site name *
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Site contact Site contact * First Last
Title/Position *
Email address
Phone number Phone number - ### - ### ####
Will students see patients in a hospital setting?

Will students see patients in a hospital setting? Yes No
Is the preceptor employed by a contracting group? *

Is the preceptor employed by a contracting group? Yes No
Student Expectations
Location & time to report (first day of rotation).

Note: If there is a consistent location and time for the student to meet the preceptor on the first day, please enter it here. Otherwise, the program will coordinate this with you.

First day of rotation
Student attire
Site specific requirements: (e.g. orientation, immunizations, BLS/ACLS, HIPAA trainings, etc.)
Additional recommendations for a student to prepare in advance for this rotation
Practice Profile
What specialty describes the care provided at this site? *

What specialty describes the care provided at this site? Emergency Medicine Family Medicine General Surgery Internal Medicine Pediatrics Psychiatry Women's Health Other Other
In what setting with students see patients?

In what setting with students see patients? Outpatient Inpatient Emergency Dept. Operating Room Other Other
Days of operation

Days of operation Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Hours of operation *
How many hours per week will the student be provided? (expected minimum of 40 hrs of engagement) *
Students will have the opportunity to work the following

Students will have the opportunity to work the following On-call Weekends Evenings/Nights Other Other
The following safety and security measures are in place at this location: (check all that apply)

Note: Students must be made aware of location of personal safety procedures and equipment and during orientation provided information on how and who to contact for emergency procedures as well as where to report if they notice any concerns regarding safety.

The following safety and security measures are in place at this location: (check all that apply)

Note: Students must be made aware of location of personal safety procedures and equipment and during orientation provided information on how and who to contact for emergency procedures as well as where to report if they notice any concerns regarding safety. Lighted parking lot Security cameras Security booth/guard Secured access to building/office Personal safety practices (PPE and safety protocols) Documentation of emergency procedures Access to reporting unsafe conditions
The daily average # of patients seen by the preceptor daily *
Students will have access to see patients in the following facilities

Students will have access to see patients in the following facilities Lab Radiology Hospital rooms Exam rooms Procedure room

Select all that apply
Students will have additional opportunities to see patients in the following facilities

Students will have additional opportunities to see patients in the following facilities Long-term care facility Hospice Home visits Rehabilitation facility

Select all that apply
Will student have access to documents in the EMR? If not, it is expected that students provide a handwritten note for feedback.

Will student have access to documents in the EMR? If not, it is expected that students provide a handwritten note for feedback. Yes No
Patient Population
The acuity level of the patient population served at this site includes

The acuity level of the patient population served at this site includes Emergent conditions Acute conditions Chronic conditions Preventative medicine
The estimated percentages by age of the patient population seen at this site
Infants
Children
Adolescents
Adults
Elderly
Does this site serve an underserved population?

Does this site serve an underserved population? Yes No
Does the practice serve a rural population?

Does the practice serve a rural population? Yes No
Preceptor Supervision
Students will encounter the following healthcare professionals at this site

Students will encounter the following healthcare professionals at this site Intern Resident Fellow PA NP Other Other
Does the site precept other students? *

Does the site precept other students? Yes No
If so, what type of students?

If so, what type of students? MD PA NP Other Other

Select all that apply
What is the preceptor/student ratio?

What is the preceptor/student ratio? 1:1 1:2 1:3 1:4 1:5
Students will have access to the following additional learning opportunities

Students will have access to the following additional learning opportunities Grand Rounds Didactic Lectures Directed Reading/Research Presentation

Select all that apply
Is supervision provided at all times?

Note: The students must have access to supervision by the preceptor or a designated healthcare provider at all times. This does not require direct observation of care provided. See Preceptor Handbook for details. *

Is supervision provided at all times?

Note: The students must have access to supervision by the preceptor or a designated healthcare provider at all times. This does not require direct observation of care provided. See Preceptor Handbook for details. Yes No
Additional information for the program

Physician's Assistant Program - Preceptor - Site Assessment Form

Physician's Assistant Program - Preceptor - Site Assessment Form

Preceptor Information

Practice Information

Student Expectations

Practice Profile

Patient Population

The estimated percentages by age of the patient population seen at this site

Preceptor Supervision