- mse - MSE

Select Your Visit Dates

Select one date per question for a total of six visits.

Visit 1 *

Visit 2 *

Visit 3 *

Visit 4 *

Visit 5 *

Visit 6 *

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

2024-2025: FCP1 Longitudinal Preceptor