Rural Summer Preceptorship Program Information and Application

WHO: M-2 Medical Students: Class of 2015
WHAT: Summer Rural Clinical Preceptorship Program
WHERE: In designated small towns and rural communities in Tennessee and surrounding states where approved preceptors and training sites are available.
HOW LONG: A continuous four week training period during June 4 through July 29, 2012.
PURPOSE: To provide medical students the unique opportunity to train and hopefully reside in a rural community, to experience the role that office-based family physicians play in rendering comprehensive medical care to their patients and families.
REQUIREMENTS FOR CONSIDERATION: Complete and return the attached Registration Form by May 25, 2012: Students must have successfully completed year one, and be in good academic standing, prepare a written report, willing to accept placement with an approved physician preceptor, and agree to participate in the four week experience on a full-time basis.
TRAINING SUPPORT: A limited number of Training Support Awards will be made to help off-set personal living/transportation expenses for those selected to participate and who complete the experience and associated educational tasks. The award, subject to final approval, will be $1,000 and selected recipients will be notified by May 28, 2012.

APPLICATION

Complete and submit the application form below. The deadline for applying is April 15. We ask your cooperation in providing some basic information, including special educational requests. This information will be helpful as we consider your application to participate in our four week 2012 Summer Rural Clinical Preceptorship Program.

Thank you for your interest in the University of Tennessee Health Science Center (UTHSC) Family Medicine's Summer Preceptorship Program. Our next training period is June 4 through July 29, 2012.

Section I

Select a training period:

First Name: Middle: Last Name:

Address:

City: State or Country: Zip:

Office Phone (with area code):

Cell Phone/Pager (with area code):

Emergency Contact and Phone (with area code):

E-mail:

Preceptor Preference & Location(if any):

Hometown (City and State/Country):

High School/Secondary School Attended: City/State and Year Graduated :

Undergraduate Education: Undergraduate City/State and Year Graduated :

Other Education (prior to Medical School): City/State, Grad Year:

Dates Available (4-8 consecutive weeks): status

Housing Needs:

If you answered "Yes," to the housing question, please explain briefly:

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Section II

Areas of Interest

List any special medical interests:

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Section III

Honors and Service

Please list any special membership honors/community service (College & Medical School):

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Experience

Work Experience (including part time; especially health related. Give type, length, location):

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Tell Us Why

Please tell us why would you like to participate in the Family Medicine Preceptorship Program:

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It will be the students' responsibility to keep the Department of Family Medicine informed of any changes in address, telephone number.

Final Steps

Please check your information and print this page before clicking "Submit". If there are any problems or questions regarding the Summer Preceptorship, please contact Sharon E. Tabachnick, Ph.D. at 901-448-3020 or stabachn@uthsc.edu. For inquiries regarding the form itself, contact Marilyn Ward at (901) 448-6032, or mward9@uthsc.edu.

To complete the submission of your preceptorship application form, in the space provided below, please type in the 2 words pictured, then click the "Submit" button. Thank you for your submission.