Dr. Dawn K. Smith (DKS) HIV Prevention Clinical Fellowship Site/Preceptor Registration Form

Dr. Dawn K. Smith (DKS) HIV Prevention Clinical Fellowship Site/Preceptor Registration Form

Contact Information

Site Name(Required)
Site Address(Required)
Primary Site Contact Name(Required)
This is the person we would contact regarding site paperwork, etc.

Mentor/Preceptor

Provide your name, title, and CVs if you desire to serve as a Mentor/Preceptor at this site. Please note that at least one of the fellow's mentors must be an Academy credentialed HIV Specialist/Pharmacist.
Mentor/Preceptor #1(Required)
How do you prefer to be contacted about this program?(Required)
Max. file size: 50 MB.
Can you precept and mentor one HIV Prevention fellow for one year beginning July 1, 2024?(Required)
Please review the requirements to serve as a Preceptor/Mentor for the The Dr. Dawn K. Smith HIV Prevention Clinical Fellowship.

Site Information

Describe the gender identities of your site's Patient Population (select all)(Required)
Enter the percentages and ethnicities below: American Indian/Native Alaskan, Asian, Black/African American, Hispanic/Latino, Native Hawaiian/Pacific Islander, White/Caucasian, Other
Does the clinic specialize in the care of any of the following populations? (Check all that apply)(Required)
Does your clinic receive funding from HRSA’s Ryan White Program?(Required)

Clinic Training Opportunities and Experience

Please enter a number from 0 to 100.
Please enter a number from 0 to 100.
Will your site offer the opportunity for fellows to gain experience in these areas? (Check all that apply)(Required)
Will fellows have access to didactic or interactive HIV education opportunities at your site such as Grand Rounds lectures, study groups, etc.?(Required)
Does your institution currently have an HIV Training Program?(Required)
Has your institution approved your ability to precept for the fellowship?(Required)