- mse - MSE

Select Your Visit Dates

There are 6 dates selected as Visit Dates. Is you are unavailable on the selected date, please list an alternate date in the following Text Box. Your alternate date should be within the week before or the week after the corresponding visit date.

Visit 1 *

Visit 1 Alternate Date

Visit 2 *

Visit 2 Alternate Date

Visit 3 *

Visit 3 Alternate Date

Visit 4 *

Visit 4 Alternate Date

Visit 5 *

Visit 5 Alternate Date

Visit 6 *

Visit 6 Alternate Date

Full Name *

Discipline or Specialty *

Email *

Telephone *

Name of Practice Site *

Practice Site Address *

Are you currently board certified?

Do you currently have a faculty appointment with the IU School of Medicine?

Name of Clinical Assistant/Scheduler

Clinical Assistant/Scheduler Work Email

Number of learners you are willing to precept per clinical group:

Additional Notes

2025-2026: FCP1 Longitudinal Preceptor