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Idaho WWAMI Medical Education Program
Rural Underserved Opportunties Program (RUOP)
RUOP Application Form
Summer 2019
Physician Name
Office Manager Name
Name of Clinic
Street Address
City, State and Zip Code
Office Phone Number
Cell Number
Email Address
HOSPITAL AFFILIATION
Name of Hospital
Address
City, State and Zipcode
Phone Number
Name of Credentialing Officer
Email Address
Would you like to be a RUOP Preceptor during the Summer of 2019?
Yes
No
Would you like to apply for UW School of Medicine Clinical Faculty Affiliation?
Yes
No
If you checked "Yes" to hosting a medical student at your clinic, please complete the following questions:
Are you available between between Monday, July 1, 2019 and Friday August 23, 2019? If so, please provide at least a 4 week consecutive window:
Available Timeframe
Will you or your community be able to provide student housing for a four week period?
Yes
No
If yes, please provide contact information and details of housing if possible:
For housing purposes, do you prefer a male or female student?
Male
Female
No preference
Which areas below best describe your medical practice?
Emergency Medicine
History and Physicals
Pediatrics
OB/Gynecology
Surgery
Geriatrics
Sports Medicine
Other (please indicate)
Which of the following best describes your clinic?
Rural Health
Community Health
Private Practice
Federally Funded Health
Hospital based clinic
Group Practice
Indian Health Services
OTHER (please indicate)
Do you know of any other family practice physician who would be interested in precepting a student this summer?
Thank you!
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