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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 eValue 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 BU Email Address
If there is a "bu.edu" email address applicable for this preceptor, please provide above
Preceptor Email Address
*
Preceptor email addresses must be an institutional email (e.g. University, Hospital). Gmail, Yahoo, and similar personal email addresses will not be accepted.
Preceptor Rank
*
Resident Educator
Attending
Clinical Rotation
*
Emergency Medicine Clerkship Selective
Family Medicine Clerkship
Geriatrics Clerkship
Medicine 1 Clerkship
Neurology Clerkship
Obstetrics/Gynecology Clerkship
Pediatrics Clerkship
Psychiatry Clerkship
Radiology Clerkship Selective
Surgery Clerkship
Ambulatory Medicine - Clinical Elective
Surgery Subspecialty – Clinical Elective
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 eValue SUPPORT TICKET
SUBMIT AN eValue SUPPORT TICKET
Your Name
*
First
Last
Your Email Address
*
eValue Support Need:
*
Please describe your eValue Support Need 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
Neurology Clerkship
Obstetrics/Gynecology Clerkship
Pediatrics Clerkship
Psychiatry Clerkship
Radiology Clerkship Selective
Surgery Clerkship
Ambulatory Medicine - Clinical Elective
Surgery Subspecialty – Clinical Elective
Other
Please select the Clinical Rotation your E*Value Issue is associated with.
Clinical Rotation (Other)
File
File
File
