School of Public Health and Health Services | George Washington University

Practicum Application - Preceptor

* indicates a required field.

Preceptor Information

First Name: *

Last Name: *

Title: *

Department:

Highest Degree Earned: * Year of Degree: *

Field (If necessary):

Years of Public Health experience: * Certifications:

Phone Number: * Fax Number:

Email Address: *

Confirm Email Address: *

I am a GW graduate.

Department/Track Preference: *

Do you have a limited service faculty appointment at GWU?

Yes

Have you previously served as an SPHHS Site Preceptor?

Yes

Are you an employee of the organization where the practicum will be conducted? (Not a volunteer, for example)*

Yes

Alternate Contact

First Name: *

Last Name: *

Title:

Department:

Phone Number: * Fax Number:

Email Address: *

Confirm Email Address: *

Professional Profile

Please paste a copy of your professional profile/resume here.*

Include years of public health and health related experience and skills gained during eduation, including dates.
Please do not submit URLs.

Primary Professional Areas or Services