JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Preceptorship (Extern) Program - Schools of Optometry Form
Within 30 days of the beginning of each academic year, the School shall furnish the following. Please submit one form per preceptee.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Institution (School) Sponsoring Preceptorship
*
Your answer
Name of Preceptee involved in a preceptorship program coming to NC
*
Your answer
Preceptee's contact information (cellphone and email address)
*
Your answer
*
3rd Year Student
4th Year Student
The name of each Preceptor
*
Your answer
The practice location(s) where the Preceptees will receive training
*
Practice Name and Address
Your answer
The projected start date of the Preceptee's training
*
MM
/
DD
/
YYYY
The projected end date of the Preceptee's training
*
MM
/
DD
/
YYYY
Please notify the Board in writing of any change of status to the above information, within 30 days of such change of status.
email:
info@ncoptometry.org
Name of Person Completing This Form
*
Please include name, title, institution and email address.
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of North Carolina Board of Examiners in Optometry.
Report Abuse
Forms
