STATEMENT OF PERSONAL DATA
Report Date:
Educational Institution:
Degree Program:
(i.e.; Med, Nsg, P.A., Pharm D., etc.)
Department Contact Person:
Phone No.:
Title:
Academic year of student:
1st
2nd
3rd
4th
Rotation:
Dates
Status
Begin:
End:
Required
Elective
Student Last Name:
Student First Name:
SSN:*
Student Email:
Date of Birth:
Race & Gender:
(Check the appropriate box)
White
Black
Hispanic
Asian
Native American
Other
Male
Female
Total Clinical Hours:
Course Name:
Preceptor or Faculty Information
Please complete the following
Rotation Supervised by:
Faculty
Preceptor
Name of Training Site:
Name:
Address:
Phone:
City,State,Zip Code
Discipline of Preceptor
-
Please mark all that apply
FM
IM
Peds
Other
Country
* this information is not being sent over a secure server. If you would prefer, you can call Judy Levy 202-638-0252 with this information.
If you need to fax this or send via US Mail, it should be addressed to:
Judy Levy
Clinical Coordinator
Medical Homes AHEC
1411 K St. Suite 1200
Washington, DC 20011
Phone: 202-638-0252
Fax: 202-638-4557
