A.T. Still University

School of Osteopathic Medicine in Arizona

Request for Preceptor Credit

Note: This form is specifically for SOMA, if you are requesting credit for time spent with a KCOM student click here.

Thank you for serving as a Preceptor for ATSU-SOMA medical students. Please complete the form below to request your CME credit.

If you have any questions, please contact the Clinical Education Department at (480) 265-8044.

* Indicates required field

Are you a D.O. or M.D.?
D.O. M.D. *


Physician First Name:
*
Physician Last Name:
*
Phone Number:
*
Email Address:
*

Rotation Details

Rotation Type:
*
(i.e. surgery, family medicine, pediatrics)
  Either student's name or rotation dates must be provided:
Student's Name:
*
Dates of Rotation:
(mm/dd/yyyy)
calendar to calendar *

Continuing medical education credit is hour for hour credit. For example, if you work 40 hours with a student, you will receive 40 CME credit hours. You should only claim the number of hours you spent with the student.

If you are in a physician group and the student spent time with more than one physician, you cannot claim the same hours as another physician.  For example, if there are two physicians in your practice, you cannot both claim 40 hours per week.

Additionally, if you had two students during the same time period, you can not claim double hours. For example, you had two students for one week, you can only claim 40 hours.

Number of Hours Requesting:
*
   

School of Osteopathic Medicine in Arizona
Clinical Educational Affairs   5850 E. Still Circle   Mesa   AZ   85206   480.265-8044
© 2013 A.T. Still University