Preceptor Lottery Request Form

REQUIRED INFORMATION – please complete all of the fields in this section. Students graduating during the current academic year will be given first priority.

Student Name

Email

Anticipated Graduation Date

Concurrent degree (ND/MSOM or ND/MSiMR)?
YesNo

Term (Check one)
SummerFallWinterSpring

I am available on the following days and times:

Monday (enter times available)

Tuesday (enter times available)

Wednesday (enter times available)

Thursday (enter times available)

Friday (enter times available)

I need ND hours only (this applies to all advanced standing students) YesNo

I am interested in (check all that apply)
AcupunctureChinese MedicineHomeopathyManipulationNutritionOB/GYNPediatricsWomen's MedicineOther

Other: If you answered other, enter modality or practice focus.

Preceptor History

How many preceptor hours have you earned toward your degree so far?

Have you previously received a preceptor lottery placement?YesNo

If so, when?

Have you worked or are you currently working with any of the preceptor lottery doctors?YesNo

If so, how many preceptor hours have you earned per doctor?

Scheduling Options

Refer to the Preceptor Lottery Schedule, available on Moodle under Clinic Resources/Clinic Schedules, when completing the fields below. Only requests for physicians from the lottery schedule, taking note of their location and availability, will be considered.

I am interested in working with the following physician(s) from the preceptor lottery schedule. (list physician name and preferred shift)

Physician Name/Shift

Physician Name/Shift

Physician Name/Shift

Physician Name/Shift

Physician Name/Shift

Physician Name/Shift

Physician Name/Shift

Are you willing to commute 10+ miles from campus to work with a preceptor lottery doctor?YesNo

Note: Once you have accepted a placement with a preceptor, you are under a professional obligation to attend that rotation. If you develop a conflict with the timing of that preceptorship, you may swap with another eligible student no later than two weeks prior to the start of the rotation. Cancellations or switches after that date are subject to 10 docked preceptor hours and a referral to the Honor Council for unprofessional conduct.