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*
Clinical Rotation*
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*
Please select the Clinical Rotation your E*Value Issue is associated with.
Clinical Rotation (Other)
File
File
File