Preceptor Program Application - University of Western States

Your participation in the University of Western States preceptorship program is greatly appreciated. This program is intended to enhance the clinical training of chiropractic interns in their 12th and final quarter who have met applicable eligibility requirements and wish to continue their training in an approved, private chiropractic practice. The objective of the preceptor program is to provide intern engagement in a wide range of practice activities under the mentorship of a field-based chiropractic physician to gain valuable real-world experience and insight relative to chiropractic practice.

This component of the UWS curriculum is designed and implemented to support the mission, goals, and objectives of UWS; to provide a mechanism to further assure competency in the cognitive and psychomotor domains of chiropractic interns; and to better prepare students for the transition from the rigors of academic life to those of a private practitioner.

Preceptor students are required to complete 27-30 weekly contract hours for up to 11 weeks in patient care. By agreeing to participate in this program, you are also agreeing to provide 27-30 hours per week of patient care for the UWS intern.

Please carefully review the required information on the preceptor application. All items and documents must be submitted with the preceptor application below.

Copy of current chiropractic license
Current curriculum vitae
Copy of current declaration of malpractice insurance
Claims history authorization
Copy of current x-ray supervisor and operator license (if applicable)

APPLICANT INFORMATION

Name

First Last

Today's Date

Office Address

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

Office Phone

Office Fax

Email Address

Website

Satellite Office Address

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

Satellite Office Phone

Satellite Office Fax

Satellite Office Email Address

Satellite Office Website

Malpractice Insurance Carrier

Expiration Date

DC License Number

Date Initially Issued

Expiration Date

Have you ever had your license suspended or revoked in your current or any other state?

Yes

Are you currently facing, or have you ever been subject to action by a state board?

Yes

Have you ever been convicted of a felony?

Yes

Have you ever had any formal disciplinary action and/ or been a party to a malpractice settlement or judgment?

Yes

Do you have a current UWS student that is interested in participating in the preceptor program at your office?

Yes

What is the name of that student?

How did you hear about the UWS preceptor program?

APPLICANT EDUCATION

Chiropractic College/Alma Mater

Graduation Year

Other Degree(s) and College(s)

Post-Graduate Residencies

Chiropractic or Other Specialty Certifications

Did you participate in a CBI/preceptorship as a chiropractic student?

Yes

Do you have current professional CPR/AED/First Aid certification?

Yes

PRACTICE INFORMATION

Average Number of Patient Visits per Week

Average Number of New Patients per Week

Indicate the following techniques used in your office:

Please check box for each technique used.

Other selected - please describe:

Indicate the following adjunctive care used in your office:

Check all that apply.

LASER selected - please list type(s):

Other selected - please describe:

Do you routinely check for vital signs? (We strongly encourage our interns to routinely check vitals.)

Yes

Identify three outcomes a UWS student would experience in your practice:

Are you providing care to patients outside of your regular clinic hours? If so, please explain.

HIPAA compliant?

Yes

Notice of privacy practice displayed?

Yes

OFFICE INFORMATION

Electronic Health Records

Yes

Software Name

Professional Licensed Staff

Please list first and last name and credentials

Ancillary/Support Staff (Front Office)

Yes

Number of Staff Members

Ancillary/Support Staff (Back Office)

Yes

Number of Staff Members

What are your regular patient clinic hours?

Please list the times and days of the week. Include lunch breaks.

DOCTOR PROFILE

In an effort to identify unique aspects of your practice, we ask that you complete the following profile which will help our interns to know more information about your practice.

Clinic Name

Location(s) (City/Clinic)

Primary techniques utilized:

Provide a brief description of your practice:

Languages spoken in practice:

What are your practice demographics (age, diversity)?

What is expected of an intern?

What duties will an intern perform in your clinic?

File Upload

All items and documents listed below must be submitted with this preceptor program application.

Resume (CV)

Max. file size: 20 MB.

Copy of current chiropractic license

Max. file size: 20 MB.

Copy of current declaration of malpractice insurance

Max. file size: 20 MB.

Copy of current x-ray supervisor and operator license (if applicable)

Max. file size: 20 MB.

Claims history authorization

Download and complete the claims history authorization form.

Max. file size: 20 MB.

ACKNOWLEDGEMENT

By checking the following, you agree that the statements herein below are true and accurate.

As a preceptor program clinician, I understand and comply with all applicable rules and I will directly supervise the intern by being present within the clinic when the intern is participating in patient care.

I certify that I do not use “Pre-Paid Fee for Service Agreements”.

I agree to comply with all relevant laws regarding the practice of chiropractic. I understand that all patients are provided a health history, are appropriately examined, receive a diagnosis, are provided a review of findings and a PARQ is completed.

I authorize UWS to access CIN-BAD/national practitioner and state or provincial data bases to verify my status to practice.

I agree to notify UWS in writing within 48 hours of any accusation filed against my license. Failure to do so will result in immediate termination from the program.

I understand that preceptor program interns may not represent themselves or be referred to as a doctor.

I have reviewed and agree to all terms and guidelines outlined therein the UWS preceptor program manual.

If you have any further comments you would like to share, please add them here.

If you have any questions regarding the application or requested documents, please call the administrative coordinator - clinical internship at 503-251-2822 or assistant dean at 503-847-2565.

E-Signature

First Last

Date