Health Care Educator Interest Form

Des Moines University Medicine and Health Sciences offers a variety of opportunities to host students for clinical education. If you are interested in hosting DMU students, please share your information and applicable program. Our team will reach out with more information.

"*" indicates required fields

Your Information

Name*

First Last

Current Position*

Office Phone*

Email*

Cellphone

Preceptor/Mentor Opportunities*

Select the mentor opportunities you’re interested in and we’ll send you more information.

Health Care Administration Preceptor

Physical Therapy Clinical Instructor

Physician Assistant Preceptor

Podiatric Medicine Preceptor

Public Health Preceptor

Occupational Therapy Fieldwork Educator

Osteopathic Medicine Preceptor

Your Practice Area(s)*

Dermatology

Emergency Medicine

Family Medicine

Internal Medicine

Obstetrics and Gynecology

Occupational Medicine

Orthopedics

Pediatrics

Psychiatry/Behavioral Medicine

Surgery

Urgent Care

Other

Other Practice Area(s)*

Are You Board Certified in Your Area(s) of Practice?*

Yes

List All Current Specialties, Sub-Specialties and Certifying Board Memberships*

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Not Board Certified (COM)

Are You Board Eligible in Your Area(s) of Practice?*

Yes, I have recently completed my post-graduate training and am actively pursuing initial certification.

When Are You Scheduled To Complete Your Boards?*

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NOT Board Certified or Eligible (COM)

We’re Sorry ...

The College of Osteopathic Medicine requires all physician preceptors be board certified or board eligible with a COM-recognized certifying board such as the American Board of Medical Specialties or the American Osteopathic Association in the specialty they teach with few exceptions. If you have questions, please contact us at COMAffiliations@dmu.edu.

For ABMS eligibility requirements, see ABMS Board Eligibility Overview and FAQ.
For AOA board eligibility requirements, see AOA Certification FAQ.

We appreciate your interest in furthering the education of our future doctors and for taking the time to apply.

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Board Certified OR Eligible (COM)

Do You Participate in Other DMU Campus Teaching Activities?

Guest Lecturing

Simulation Lab

SPAL

Member of a DMU Board

Degree Information

Primary Degree*

D.O.

M.D.

Other

Medical Degree Institution*

Graduation Year*

Primary Degree*

Other Degree(s)

Date of Successful Completion of Training (Residency, Fellowship, etc.)

(Residency, Fellowship, etc.)

Site Information

Office Site Name

Office Site Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Does Your Site Have a Clinical/Education Coordinator?

Yes

Clinical/Education Coordinator Name*

First Last

Clinical/Education Coordinator Email*

Clinical/Education Coordinator Phone*

Additional Information We Should Know About Your Site

(e.g. Website, Other Locations, Corporate Ownership, Staff)

Attestation

Have you ever been placed on probation or asked to resign an internship or residency training program?*

Yes

If Yes, Please Explain*

Have you ever been disciplined for a violation of ethical standards by a professional organization?*

Yes

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

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

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

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

If Yes, Please Explain*

Has your malpractice insurance been denied, suspended, limited, not renewed or terminated by a carrier?*

Yes

If Yes, Please Explain*

Are you currently or within the past three years been named in a lawsuit or medical malpractice claim?*

Yes

If Yes, Please Explain*

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Teaching Statement

COM Teaching Statement*

With this teaching agreement, I will assist in providing clinical training for Des Moines University’s College of Osteopathic Medicine medical students. In addition, I agree to follow the curriculum provided by the COM Clinical Affairs department. I 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 COM’s continual faculty evaluation process, 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.

I will review and comply with DMU’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. I understand this agreement may be terminated without cause at any time by COM. I understand that COM will provide me in advance 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 the COM Clinical Affairs department. This agreement in no way obligates COM to provide any specific number of students to rotate with me during any given time period.

I have read and agree to the College of Osteopathic Medicine teaching statement and DMU’s code of conduct.

Preceptor Signature*

Your Information

Not Board Certified (COM)

NOT Board Certified or Eligible (COM)

We’re Sorry ...

Board Certified OR Eligible (COM)

Degree Information

Site Information

Attestation

Teaching Statement

Contact DMU

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