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students: _________________________________\n Cell: ________________________ Email: ________________________________________________________\n \n List all locations/clinics for the practice (use a separate sheet if more convenient):\n __________________________________________________________________________________________\n __________________________________________________________________________________________\n \n Do any locations serve health disparity minorities or have HRSA designations i.e. FQHC, CHC, HPSA, MUA?\n \n __________________________________________________________________________________________\n \n Other information about site or locations: \n __________________________________________________________________________________________\n _________________________________________________________________________________________\n __________________________________________________________________________________________\n \n \n #2: Location Information (complete a new form for each location) \n \n Name and address of clinic, and any special information about the location or parking:\n __________________________________________________________________________________________\n __________________________________________________________________________________________\n __________________________________________________________________________________________\n \n Clinic manager to contact for student placement or onboarding: _______________________________________\n Cell: ________________________ Email: ________________________________________________________\n \n Any Special Onboarding? \n __________________________________________________________________________________________\n __________________________________________________________________________________________\n __________________________________________________________________________________________\n \n \n \n \n \n \n \n \n " }, { "page": 2, "w": 612, "h": 792, "text": " \n \n \n \n \n \n Age range of patients at this location Clinical Specialty: \n ______ % Pediatric (0 - 18 years) Family Practice \n ______ % Adult (18 \u2013 64 years) Internal Medicine \n \n ______% Geriatric (65+ years) Pediatrics \n Women\u2019s Health \n Type of Setting Emergency Medicine \n \n ______ % Outpatient Surgery \n ______ % Inpatient Infectious Disease \n ______% Emergency Department Behavioral Health \n \n ______ % Operating Room Elective (specify) _____________________\n ______% Other (specify) _____________________ \n \n Do students need to speak a 2nd language to communicate effectively with patients? ______________________\n \n Language: ______________________________________ What percentage of patients speak this?________%\n \n \n \n #3: Information on Providers / Preceptors at the Location \n \n 1st ____________________________________________________________________________________ 1-3 4-6 7-10\n Name (MD, DO, PA, NP) Number of students preceptor will take (per academic year)\n \n _________________________________________________________________________________________________________________\n License, Board Certification and Supervising Physician (if provider is a PA) \n Email: _____________________________________________________Phone: _________________________\n \n Any preference on times to take or not take a student?______________________________________________\n \n 2nd_____________________________________________________________________________________ 1-3 4-6 7-10\n Name (MD, DO, PA, NP) Number of students preceptor will take (per academic year)\n \n _________________________________________________________________________________________________________________\n License, Board Certification and Supervising Physician (if provider is a PA) \n \n Email: _____________________________________________________Phone: _________________________\n \n Any preference on times to take or not take a student?______________________________________________\n \n \n \n *The notification email sent prior to each rotation contains the following documentation in the Student Profile link:\n \n Student photo and contact information BLS and ACLS certifications \n Background check and drug screen OR training (scrubbing, gowning, gloving)\n Immunization records Clinical skills documentation \n Certificate of liability (malpractice) insurance DFW Hospital Council standard student orientation\n \n \n \n " } ] }