Educational Opportunities Survey

Educational Opportunities Survey Physician Assistant Program Baylor College of Medicine Houston, Texas

This section is to be completed by the health care provider with whom the student will work. Please attach a copy of the curriculum vitae for all health care providers to supervise the student (including Allied Health personnel).

1. Please check the educational opportunities that you feel your practice could provide, with supervision, for a student during a four, eight or twelve-week clinical rotation: ( ) Ability to see at least 4 patients per half day. ( ) Make at least one nursing home visit on the rotation. ( ) Make at least one home visit while on the rotation. ( ) Provide continuity of care by following a patient from setting to setting, visit to visit. ( ) Refer a patient to a community agency and obtain follow-up. ( ) Perform minor office surgery. ( ) Observe/perform Well-Woman Exam ( ) Observe deliveries. ( ) Perform deliveries. ( ) Learn circumcisions. ( ) Obtain on-call experience. ( ) Obtain ER experience. ( ) Other:______

2. Would your practice be willing to take a PA student for 4 weeks, 8 weeks, or 12 weeks? (please circle all that apply)

3. Please indicate the months in which your practice could take a student.

( ) January ( ) March ( ) May ( ) July ( ) September ( ) November ( ) February ( ) April ( ) June ( ) August ( ) October ( ) December

4. In which areas of your practice will the student be involved?

___ Office Practice ___ Community Medicine Program/ Project Screening ___ Hospital Rounds ___ School Health ___ Clinics ___ Sports Medicine ___ ER ___ OR ___ In-patient care ___ Nursing Home ___ Other: ___ Other Areas:

D:\Docs\2018-04-16\07dc2abecc406041878988098231373a.doc 5. What will be the schedule and the expected hours for the student?

Hours Location Hours Location Monday [to] Friday [to] Tuesday [to] Saturday [to] Wednesday [to] Sunday [to] Thursday [to]

On –call frequency ______Location: home/ hospital/ office/ other:

6. For Family, Community, and Internal Medicine practices, please check the 10 most common diagnoses you see in an average month:

Routine Physical Dizziness/Vertigo Chronic Fatigue URI CAD/MI Depression/Anxiety Pharyngitis Hypertension Back Pain Tonsillitis COPD Sports Injuries Sinusitis Asthma Lacerations Bronchitis Gastroenteritis BPH Allergic Rhinitis Chronic Bowel Dz. Vaginal Discharge Conjunctivitis Anemia Dysmenorrhea Rash UTI Menopause Headache Renal Disease DUB

7. Will the student be working with other physicians, practicing physician assistants or nurse practitioners? If yes, please attach their CVs to this form as well as your own.

8. Hospital and Nursing Home Staff Affiliations: (please list)

1. Physician Allied Health Personnel 2. 3. 4.

Do you or the hospital need PA Program documents, letters or assistance in obtaining hospital or nursing home temporary practice privileges? Yes / no

If “yes”, what type of assistance is needed from us?

Do these facilities allow students to participate in patient care? Yes / no

D:\Docs\2018-04-16\07dc2abecc406041878988098231373a.doc Comments including student restrictions at above sites:

9. If you currently precept other students in your practice, what type of students and what programs? (please list)

Baylor students will / will not be working in your practice with other students?

10.Are you willing to accept students without regard to race, color, or sex? Yes / no

11.Are you willing to participate in faculty development sessions? Yes / no

12.Professional and Community Meetings

Will you take the student to professional and community meetings you usually attend such as clinic or hospital medical staff meetings, county medical society meetings, and community service organizations? Yes / no

Thank you for completing this information. Please remember to attach the CVs for you and your professional staff.

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