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Membership
Join / Renew
Membership Dues
Member Journey
Student Membership
Resident/Fellow Membership
State & Regional Chapters
Member Spotlight
Credentialing
HIV Specialist™
HIV Pharmacist™
HIV Expert™
Examination Dates & Retake Policy
Academy Mentoring Program
Sample Questions
AAHIVM Credential Verification
Advocacy and Policy
Policy Position Statements
National Issues
HIV Policy Update
Provider Resources
Clinical Education Center
Core Curriculum
Primary Care & HIV
Sexual Health Curriculum
National HIV & Aging Initiative
Women & HIV
Academy Webinar Series
Long-acting Agents Resource Center
Guidance & Recommendations
Clinical Information
PrEP Guidelines & Recommendations
Professional Support
Academy Communities
Academy Mentoring Program
Accredited CE Opportunities
Patient Assistance Resources
Intensive Course in HIV & Aging
Transgender Health Resource Center
Career Center
Physician Assistant Preceptorship Program
Training Opportunities
Publications
HIV Specialist Magazine
Fundamentals of HIV Medicine
Cabenuva® Factsheet
Clinical Research Update
HIV Policy Update
The Academy Exchange Podcast
Cesar Augusto Caceres Award for Innovations in HIV Prevention & Care
Events
Workshops
Webinars
2024 National Conferences
About
Board of Directors
Staff
DEI Statement
Academy Council for Racial Equity
COI Statement
Corporate Scientific Advisory Board
Press Releases
Privacy Policy
Contact Us
PHYSICIAN ASSISTANT PRECEPTOR SIGN-UP
What is your name?
First
Last
Preferred Pronouns
Email
Phone
How do you prefer to be contacted about this program?
Email
Phone
Either/Both
In which state(s) and/or territories are you licensed?
What is your supervising physician's name?
First
Last
In which state(s) and/or territories is your supervising physician licensed?
What is the name and physical address of your facility/practice site?
What are your supervising physician's board certifications and/or areas of specialty practice?
Describe your practice setting (ie: hospital, public health, community health, etc.)
Which best describes the primary specialty of your practice?
Family Medicine
Internal Medicine
Infectious Disease
Pediatrics
Geriatrics
OB/GYN
Emergency Medicine
Behavioral Medicine
Other
What are your typical workday hours? (start time and finish time)
What is the average number of patients you see per day?
Approximately what percentage of your patient load is people with HIV?
Please enter a number from
0
to
100
.
Are you currently a preceptor for PAs? If so, for what programs?
Are you available and allowed to precept students from outside your own state?
Yes
No
Unsure
For which of these timeframes would you be available to precept?
2 week rotation
4 week rotation
6 week rotation
8 week rotation
10 week rotation
If you already precept, do you have any specific dates open throughout the year?
Would there be any additional preceptors on site for the student other than yourself?
Yes
No
Unsure
Please tell us anything that is special, unique, interesting, or noteworthy about your practice, your patient population and/or your precepting style?
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