Council on Curriculum Family Medicine Preceptorship Questionnaire Main MenuClose Main MenuClose Admissions About our School Programs Electives Students Residents Faculty Alumni & Friends News Events Research Directories Giving Tour Report Mistreatment Curriculum Home Informational Updates Council Structure & Subcommittees Council on Curriculum Clerkship Director’s Subcommittee Course Director’s Subcommittee Curriculum Steering Subcommittee Student Curriculum Ambassadors Curriculum Policies Curriculum & Rotation Information United States Medical Licensing Examination Step 1 / Step 2 CK Policies Clerkship Policies Elective Policies Petition Policies Competency-Based Curriculum Guide Forms Resources Contacts Council on Curriculum UMKC School of Medicine MG-200 (Ground) 2411 Holmes Street Kansas City, MO 64108 Phone: 816-235-1852 Fax: 816-235-1851 Family Medicine PreceptorshipPlacement Questionnaire Preceptorship Block:*Select BlockBlock 1Block 2Block 3Block 4Block 5Block 6Block 7Block 8Block 9Block 10Block 11Block 12Block 13Name and contact information: Last* First* Cell Phone:* Area Code - Phone Number E-mail:* Current Local Address: Street Address City State Postal / Zip CodePlease answer the following: Do you have children?YesNo Are you scheduled for Patient Physician Society (PPS) this fall?YesNoMissouri Residents: Did you ever participate in AHEC programs during middle or high school?YesNo If yes, which region of the state?Select regionNorthwestNortheastCentralSoutheastSouthwestIf you’re placed at a preceptor site that requires a universal drug screening you will be required to obtain and pay for one.Five of the six medical schools in Missouri require a rural rotation. This means there is considerable competition for both preceptors and housing. Students are welcome to submit their preferences with the understanding that there is no guarantee that the physician or location will be available. All placements are based on availability of preceptors and housing. We face a continued shortage of preceptor sites, therefore listing additional housing locations gives you a higher chance of placement during your block and avoids delaying preceptor, which may result in extensive schedule changes.Please enter all locations in Missouri where you have available housing. Location #1 Location #2 Location #3Please note: Potential weather conditions during the scheduled month of Preceptorship will be given serious consideration when assigning a location.EXCUSED ABSENCESAs stated in the placement and course policy document, a maximum of two days absence will be allowed by the department –any other absence requests submitted to other departments [even if approved], will not be considered. Students must submit a formal clerkship absence excuse form at least four weeks before the start of Preceptorship. Absence requests are approved by the course director not the preceptor.Note: Orientation and Wrap-Up sessions are mandatory; absence requests for these days will not be approved.Please do not contact any Preceptor Physicians – all placements are set up by the clerkship coordinator and/or the clerkship director.After reading the Family Med II Preceptorship Placement Policies document, please note any other concern you would like taken into account during the placement process. If you inadvertently omit a concern, please notify Emily Wade at WadeEG@umkc.edu.SubmitReset