American Academy of HIV Medicine | Physician Assistant Preceptee Sign-Up

PHYSICIAN ASSISTANT PRECEPTEE SIGN-UP

Name

First Last

Preferred Pronouns

Phone

Your Hometown (city/state)

PA Program Name

PA Program City/State

Would you like to receive a free subscription to the Academy's HIV Specialist magazine?

Yes

Subscription Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

When do your rotations start?

Please provide an approximate date

Please list your rotation blocks with Exact Dates

Use the +/- buttons to add additional rotation dates.

Rotation Number (ie: R1, R2)

Is this block open for an HIV rotation? (yes/no)

Start Date

End Date

Does your school allow for rotations outside your state?

Yes

Are you able and willing to travel outside of your local area?

Yes

How far are you willing to travel for an HIV rotation?

10) Do you have any special interest in certain areas of medicine already?

11) Is there anything else you would want a potential preceptor to know about you, about your interests, your background, where you would like to work in the future?

Please attach your resume. It will be shared with potential preceptors.

Max. file size: 50 MB.

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PHYSICIAN ASSISTANT PRECEPTEE SIGN-UP

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