Name

Name of Employer, Group or Solo Practice

Address

City    State       Zip

Phone

Fax

Board Certification (list)

AOA# (if applicable)

Hospital Privileges(City and State)

Contact Person (Practice Manager or Other Contact)

Contact Person Phone

Contact Person Fax

Contact Person Email

Member of Tennessee Osteopathic Medical Associati on? Yes No

Clinical Rotations:

Hospital Supervision
Med Students - Yes
Med Students - No
PA Students - Yes
PA Students - No

Office Preceptorship/Clerkship
Med Students - Yes
Med Stu dents - No
PA Students - Yes
PA Students - No

I will take students on a regular basis.

This is a one- time commitment

If one-time commitment, please provide student's name:

Other Areas of Interest:

Lectures on Campus
Med Students - Yes
Med Students - No
PA Students - Yes
PA Students - No

Facilitate and Teach on Campus (OMM and/or Clinical Skills Labs)
Med Students - Yes
Med Students - No
PA Students - Yes
PA Students - No

Full Time or Part Time Campus Faculty
Med Students - Yes
Med Students - No
PA Students - Yes
PA Students - No

Participate in Student Interview Process
Med Students - Yes
Med Students - No
PA Students - Yes
PA Students - No

Participate in Student Shadowing and DO Letter of Recommendation to LMU-DCOM
Med Students - Yes
Med Students - No
PA Students - Yes
PA Students - No

Other special interests: