# PRACTICE DATA PROFILE — Field Map (for Q&A fill)

Source: UT Southwestern Medical Center, Dept. of Physician Associate Studies.
PDF: /tmp/practice-data-profile/blank.pdf (2 pages)
Form type: INTERACTIVE AcroForm. 57 fillable fields (42 text /Tx + 15 checkbox /Btn).
Fill method: AcroForm fill (set field values by exact field name). NO overlay needed.
Field names below are the EXACT PDF field names (use verbatim for the fill step).
Coordinates/rects for every field are in /tmp/practice-data-profile/extract.json.

NOTE on naming: page-1 fields are human-readable; page-2 fields are generic
("Text6", "Check Box26-1"...). The label mapping below was resolved from the
on-page coordinates + visual layout, so it is reliable.

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## SECTION 1 — Affiliation Agreement Information (page 1)

- "Date" (text) — Date the form is completed
- "Legal name of practice" (text)  [Exult standard — likely "Exult Healthcare PLLC", CONFIRM]
- "Corporate Address" (text)
- "City" (text)
- "State" (text)
- "Zip" (text)
- "Office Phone" (text)
- "Fax" (text)
- "Person who will sign affiliation agreement for the practice" (text)
- "Cell" (text) — cell for the affiliation-agreement signer
- "Email" (text) — email for the affiliation-agreement signer
- "Person who will receive placement notifications and onboard students" (text)
- "Cell_2" (text) — cell for the placement/onboarding contact
- "Email_2" (text) — email for the placement/onboarding contact
- "List all locationsclinics for the practice use a separate sheet if more convenient 1" (text, multi-line) — all locations/clinics for the practice
- "Do any locations serve health disparity minorities or have HRSA designations ie FQHC CHC HPSA MUA" (text) — Y/N + detail; HRSA = FQHC, CHC, HPSA, MUA
- "Other information about site or locations 1" (text, multi-line)

## SECTION 2 — Location Information (page 1; "complete a new form for each location")

- "Name and address of clinic and any special information about the location or parking 1" (text, multi-line)
- "Clinic manager to contact for student placement or onboarding" (text)
- "Cell_3" (text) — cell for the clinic manager
- "Email_3" (text) — email for the clinic manager
- "Any Special Onboarding 1" (text, multi-line)

## SECTION 2 (cont.) — Demographics / Setting / Specialty / Language (page 2)

Age range of patients (percentages — should total 100%):
- "Text6" (text) — % Pediatric (0-18 years)
- "Text7" (text) — % Adult (18-64 years)
- "Text8" (text) — % Geriatric (65+ years)

Type of Setting (percentages — should total 100%):
- "Text9" (text)  — % Outpatient
- "Text10" (text) — % Inpatient
- "Text11" (text) — % Emergency Department
- "Text12" (text) — % Operating Room
- "Text13" (text) — % Other
- "Text1" (text)  — Other (specify): what the "Other" setting is

Clinical Specialty (CHECKBOXES — check all that apply; check by setting /V to the
box's on-state, typically "/Yes" or "/On"; confirm at fill time per box):
- "Check Box26-1" — Family Practice
- "Check Box26-2" — Internal Medicine
- "CheckBox26-3"  — Pediatrics
- "CheckBox26-4"  — Women's Health
- "CheckBox26-5"  — Emergency Medicine
- "Checkbox26-6"  — Surgery
- "Checkbox26-7"  — Infectious Disease
- "Checkbox26-8"  — Behavioral Health
- "Checkbox26-9"  — Elective
- "Text27" (text) — Elective (specify): which elective specialty (only if Elective checked)

Language:
- "Text28" (text) — Do students need to speak a 2nd language to communicate effectively with patients? (Y/N + detail)
- "Text29" (text) — Language (which language)
- "What percentage of patients speak this" (text) — % of patients who speak that language

## SECTION 3 — Providers / Preceptors at the Location (page 2)

Preceptor #1:
- "Text30" (text) — Name (MD, DO, PA, NP)
- Number of students preceptor will take per academic year (CHECKBOX — pick ONE):
    - "Check Box34" — 1-3
    - "Check Box35" — 4-6
    - "Check Box36" — 7-10
- "Text31" (text) — License, Board Certification and Supervising Physician (if provider is a PA)
- "Text3" (text)  — Email
- "Phone" (text)  — Phone
- "Text4" (text)  — Any preference on times to take or not take a student?

Preceptor #2:
- "Text33" (text) — Name (MD, DO, PA, NP)
- Number of students preceptor will take per academic year (CHECKBOX — pick ONE):
    - "Check Box40" — 1-3
    - "Check Box41" — 4-6
    - "Check Box42" — 7-10
- "Text32" (text) — License, Board Certification and Supervising Physician (if provider is a PA)
- "Text2" (text)   — Email
- "Phone_2" (text) — Phone
- "Any preferences on times to take or not take a student" (text) — time preference

(Form has room for only 2 preceptors. If more, attach a separate sheet.)

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## Footnote (no input — informational only)
The notification email sent prior to each rotation includes, in the Student Profile link:
student photo & contact info; background check & drug screen; immunization records;
certificate of liability (malpractice) insurance; BLS & ACLS certifications;
OR training (scrubbing, gowning, gloving); clinical skills documentation;
DFW Hospital Council standard student orientation.

---

## Exult-standard candidates (pre-fill, then CONFIRM with Gautam)
- "Legal name of practice" → likely "Exult Healthcare PLLC"
- "Corporate Address" / "City" / "State" / "Zip" → Exult practice address
- "Office Phone" / "Fax" → Exult main line / fax
- "Person who will sign affiliation agreement..." → likely Gautam (confirm exact name/title)
- placement/onboarding contact + clinic manager → confirm who handles student onboarding

## Notes for the fill step
- Use AcroForm fill (pypdf update_page_form_field_values, or pdftk if installed).
- Set NeedAppearances so values render in all viewers.
- For checkboxes, read each /Btn's /AP /N keys to learn the exact on-state name
  ("/Yes" vs "/On" etc.), then set /V + /AS to that value.
- Percentage groups should each sum to 100 (age range; type of setting).
- Section 2 + 3 are per-location: a separate copy/fill is needed for each location.