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_________________, a third year medical student at the University of Texas Medical Branch has
requested permission to have you serve as a preceptor. We are requesting some basic information so
that we might add you to our list of approved preceptors. We would appreciate your taking the time to
provide the information listed below.
Email Address:__________________________________________________________________
Please indicate your practice discipline: [ ] Family Medicine [ ] Internal Medicine [ ] Pediatrics
Thank you for taking the time to provide this information. The student will bring with him/her an evaluation
form that you should fill out at the conclusion of the preceptorship. You will also be sent a course syllabus
which states the curriculum goals and objectives. If you have any questions or concerns about the
student’s performance during the preceptorship, please do not hesitate to call.