- mse - MSE

Select Your Visit Dates

Select one date per question for a total of four visits

Visit 1 *

Visit 2 *

Visit 3 *

Visit 4 *

Full Name *

Discipline or Specialty *

Email *

Office Phone *

Direct Phone

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

Clinical Assistant/Scheduler Phone

Preceptors will be assigned two FCP2 students. Please indicate if you prefer to host both of your students on the same afternoon. If you select that you want your students on different afternoons, we will use the alternate date (listed above) as the visit date for the second student, unless indicated otherwise in the additional notes below.

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

Additional Notes

2024-2025: FCP2 Longitudinal Preceptor