A.T. Still University

Kirksville College of Osteopathic Medicine

Request for Preceptor Credit

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

Thank you for serving as a Preceptor for 3rd and/or 4th year ATSU-KCOM medical students. Please complete the form below to request your CME credit.

This form is for 3rd and 4th year KCOM clinical rotations.  Do not complete this form to request credit for the Early Clinical Experiences Rotations completed with 2nd year students.  Please contact the Missouri AHEC Program at 660.626.2887 regarding credit for 2nd year students.

If you have any questions, please contact the Academic & Clinical Educational Affairs office at 660.626.2187.

* 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:
Yes No

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:
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. You cannot claim more than 80 hours for a 2-week rotation or more than 160 hours for a 4-week rotation.

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 cannot claim double hours. For example, you had two students for one week, you can only claim 40 hours.

Number of Hours Requesting:

Kirksville College of Osteopathic Medicine
Academic & Clinical Educational Affairs   800 W. Jefferson   Kirksville   Missouri   63501   660.626.2187
© 2015 A.T. Still University