NMAETC - National Minority AIDS Education and Training Center

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Preceptorship Request Form

NMAETC preceptorships are a series of structured and integrated didactic presentations, case studies and clinical experiences under the direction of expert faculty and clinicians. Please fill out the form below to indicate your areas of interest.

Applicant Information

First Name * Last Name * Address * City * State * ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Code *
Phone * Fax Cell Email * Type of Practice * Specialty * Currently treating HIV patients? Choose Yes No If yes, how many? Choose 1-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 Race Choose African African-American Asian Carribean Latino Native American White Other Gender Choose Male Female

Emergency Contact Information

Name Relationship Telephone Cell Address City State ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Code

Education

Highest Level Acheived Choose MD PhD Masters Bachelors Other

Residency / Internship

Institution From date To date Address City State ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Code
Department Address City State ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Code
Related Medical / Dental / Nursing / Pharmacy Experience
Clinical Management Interest
Preceptorship Objectives

Specific Areas of Interest

Nursing Pediatrics Dental Pharmacy Other

Topics of Interest

HAART Opportunistic Infections Resistance Testing & Interpretation Cultural Competence HIV & Hepatitis B/C Co-infection HIV & Pregnancy HAART & Drug Interactions HIV & Co Morbidities Other

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Calendar of Events

Protecting You(th): State of HIV/AIDS in Native America - BESAFE Facts

Tue Mar 16

Los Angeles, CA

Changing HIV Stigma

Fri Mar 19

Kinder, LA

National Native AIDS Awareness Day & BESAFE Barriers

Sat Mar 20

McAlester, OK

» Go to Calendar of Events

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Capacity Building Services

Learn more about our services and how we can help you.

» Get Capacity Building Assistance here