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Preceptor/Field Instructor Nomination Form
Support for Students
Preceptors of the Year
This award recognizes preceptors/field instructors who have trained students in the 2018–2019 academic year.
Recipients will be recognized at the Primary Care Summit on October 18, 2019.
Nominations are due August 31st, 2019!
Name of nominated preceptor/field instructor
Name of site
Address and phone number of site
Preceptor/field instructor profession
Which of the following core topic areas does the preceptor/field instructor provide experience/training to students?
Behavioral Health Integration
Social Determinants of Health
Current and Emerging Health Issues
Please specify which current and emerging health issues this preceptor/field instructor provides training for, if any.
In 4–6 sentences, please detail how in the past year the preceptor/field instructor has provided training or experience to students in the selected topics above:
In 4–6 sentences, please provide details on why you think this preceptor/field instructor is deserving of
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