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E*Value Help Desk
E*VALUE HELP DESK
PRECEPTOR PROFILE ADDITION REQUEST
PRECEPTOR PROFILE ADDITION REQUEST
Please provide the following information if you would like to request the addition of a preceptor's profile to E*Value so that you may initiate an ad hoc Evaluation about/to them
Your Name
*
First
Last
Your Email Address
*
Preceptor Name
*
First
Last
Credential (ex. MD, NP, PA, PhD)
Preceptor Email Address
*
Preceptor Rank
*
Resident Educator
Attending
Clinical Rotation
*
Emergency Medicine Clerkship Selective
Family Medicine Clerkship
Geriatrics Clerkship
Medicine 1 Clerkship
Medicine 2: Ambulatory Medicine Clerkship Selective
Neurology Clerkship
Obstetrics/Gynecology Clerkship
Pediatrics Clerkship
Psychiatry Clerkship
Radiology Clerkship Selective
Surgery Clerkship
Surgery Subspecialty Clerkship Selective
PA Program
Other
Please select the Clinical Rotation you would like this preceptor to be available for.
Clinical Rotation (Other)
Additional Information?
If you have 5 or more Preceptor Profiles to request at one time, please use
this template
and upload below.
File
File
File
SUBMIT AN E*VALUE HELP TICKET
SUBMIT AN E*VALUE HELP TICKET
Your Name
*
First
Last
Your Email Address
*
E*Value Issue
*
Please describe your E*Value Issue in detail and include all relevant information. If necessary, please include Module/Course/Rotation name, Block, Site Name, and Student/Faculty Names & Faculty Rank (Resident Educator/Faculty).
Clinical Rotation
*
Emergency Medicine Clerkship Selective
Family Medicine Clerkship
Geriatrics Clerkship
Medicine 1 Clerkship
Medicine 2: Ambulatory Medicine Clerkship Selective
Neurology Clerkship
Obstetrics/Gynecology Clerkship
Pediatrics Clerkship
Psychiatry Clerkship
Radiology Clerkship Selective
Surgery Clerkship
Surgery Subspecialty Clerkship Selective
PA Program
Other
Please select the Clinical Rotation your E*Value Issue is associated with.
Clinical Rotation (Other)
File
File
File
