1Applicant Information2Practice and Affiliated Hospitals3Disclosure Applicant InformationFull Legal Name* First Middle Last Suffix Maiden/Alternate Name(s) (if applicable)Primary Degree* D.O. M.D. Medical Degree Institution*Graduation Year*Date GraduatedDate of Successful Completion of Training (Residency, Fellowship, etc.)*AOA #Email* Date of Birth* Month Day Year Gender Male Female Prefer Not to Answer Race or Ethnicity American Indian or Alaska Native Arabic (non EEO category) Asian (not Hispanic or Latino) Black or African American Hispanic or Latino Indian Middle Eastern Native Hawaiian or other Pacific Islander White Other Prefer not to answer Board Certified* Yes No Please list all current board certifications*If not board certified, please explain:* I'm in the process of completing my boards My boards are currently scheduled Board Eligible* Yes No We're sorry...Our accrediting body requires that all our preceptors be either board certified or eligible with the American Board of Medical Specialties (ABMS) and/or the American Osteopathic Association (AOA). If you have any questions, please feel free to reach out to us at COMAffiliations@dmu.eduFor ABMS eligibility requirements, visit ABMS Board Eligibility Overview and FAQs.For AOA board eligibility requirements, visit AOA Certification FAQs.We greatly appreciate you for taking the time to apply and for your interest in furthering the education of our future doctors.SpecialtySubspecialtyAre you interested in providing student shadowing experiences? Yes No Are you currently providing rotations for DMU DO students? Yes No How many rotations per year are you providing?Would you be willing to take students for clinical rotations? Yes, I am willing to take 3rd or 4th year students Yes, but I only wish to take 4th year students No How should a student or DMU clerkship coordinator go about requesting/scheduling a rotation with you? I schedule my own rotations; contact me directly A different individual should be contacted Rotations with me are scheduled through VSAS Person to contact about scheduling rotations First Last Contact Email Contact PhoneIf any free or affordable housing is made available for students completing a rotation with you, please list the details:Are you participating in any other DMU campus teaching activities? Please check all that apply: Guest Lecturing SIM Lab SPAL Member of a DMU Board Primary PracticeOffice NameAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Office PhonePrimary/Cell PhoneIs the contact person for this office different than the applicant? Yes No Practice Contact PersonName First Last PhoneEmail FaxAffiliated Hospital(s)Please list all locations that may take studentsHospitalsNameAddressCityStateZipPhone DisclosureHave you ever been placed on probation or asked to resign an internship or residency-training program?* Yes No N/A If yes, please explain*Have you ever been disciplined for a violation of ethical standards by a professional organization?* Yes No N/A If yes, please explain*Have you voluntarily or involuntarily had a state, district or federal professional license or registration (DEA or State Controlled Substance Certificate), board certification or any other certification revoked, suspended, limited, denied or refused by an Iowa licensing, state or federal drug administration, certifying board, or by such an entity in any other state(s)?* Yes No N/A If yes, please explain*Have your employment, medical staff appointment/membership, or clinical privileges been challenged or voluntarily or involuntarily suspended, reduced, revoked, refused (denied), relinquished, terminated, limited or lost at any hospital, healthcare plan or other healthcare facility or organization?* Yes No N/A If yes, please explain*Have you been convicted of, found guilty of or pled no contest to a felony, grand jury indictment or crime, or other than a minor traffic violation?* Yes No N/A If yes, please explain*Do you presently have a physical, mental or emotional condition (including alcohol or drug dependence), or do you presently engage in the use of illegal substances that affects or is reasonably likely to affect your ability to perform your professional duties appropriately or which could adversely affect the quality of care rendered by you to patients or jeopardize the safety of patients?* Yes No N/A If yes, please explain*Has your malpractice insurance been denied, suspended, limited, not renewed or terminated by a carrier?* Yes No N/A If yes, please explain*Are you currently or within the past three years been named in a lawsuit or medical malpractice claim?* Yes No N/A If yes, please explain*Teaching StatementWith this teaching agreement, I will assist in providing clinical training for Des Moines University’s College of Osteopathic Medicine (COM) medical students. In addition, I agree to follow the curriculum provided by the clinical affairs department of the COM. I will also agree to review, monitor, and provide comments for the revision of the COM curriculum as needed. Upon the completion of each individual student rotation I will, within 14 days, fully complete and return to COM a student rotation evaluation form. I also understand that a site evaluation will be required from each student I train. I understand that this is only one part of the continual faculty evaluation process at COM, and that I am also expected to contact COM regarding current, past, or future students, its curriculum, or if I have questions and comments regarding grading or training procedures of the College. I will review and comply with Des Moines University’s code of conduct, and will not discriminate against any student on the basis of race, religion, ethnicity, creed, color, sex, age, sexual orientation, disability, veteran status, or national origin. With this agreement, I affirm that I am duly licensed to practice medicine and am not currently nor have been sanctioned by any licensing board or excluded by Medicare/Medicaid. I have in effect current medical malpractice insurance, and have appropriate privileges to practice my specialty at an area hospital in the state where I reside. I will give immediate written notification to COM of any changes in my practice status. This agreement may be terminated without cause at any time by COM. I understand that COM will provide me in advance with a list of any changes in the approved student rotation schedule. I may, at my discretion, make needed changes in my availability for teaching by contacting COM in writing prior to the change. I may refuse any student(s) by notifying the office of the associate dean for clinical affairs of the COM. This agreement in no way obligates COM to provide any specific number of students to rotate with me during any given time period.Preceptor Signature* Δ
