OHSU Home > Regional Outreach > Office of Rural Health > Recruiting > Recruitment Assistance Form

Recruitment Assistance Form

Rowena Crest, Columbia Gorge

Please complete the form below. The information you provide will be used to market your community and practice opportunity; therefore, it is important to be as thorough as possible. Please complete one form per practice opportunity.

Primary Care Opportunities

Please indicate the number of opportunities for each specialty and the proposed hire date:

FP* Number and Hire Date:

IM Number and Hire Date:

PED Number and Hire Date:

IM/PED Number and Hire Date:

PA or FNP Number and Hire Date:

PA (only) Number and Hire Date:

FNP (only) Number and Hire Date:

CNM Number and Hire Date:

Other (specify):

*OB required for FPs?:

Yes

Optional

Practice Site Information

Name of Practice Site:

Address:

City:

State:

Zip:

Contact (Person responsible for recruiting):

Contact's Title:

Phone:

Fax:

E-mail:

Name of Corporate Owner (if different):

Corporate Address:

City:

State:

Zip:

Corporate Contact:

Contact's Title:

Phone:

Fax:

E-mail:

More Practice Site Information

Call coverage for physicians:

Yes

If Yes, 1 in:

Number of Physicians at site:

Call Coverage for Mid-levels?:

Yes

If Yes, 1 in:

Number of Mid-levels at site:

Accept Medicare/Medicaid?:

Yes

Accept indigent patients?:

Yes

Practice Description (check all that apply):

Solo

Solo w/Assoc.

Hospital-based

Community-based

Community/Migrant Health Center

Partnership

State Institution/Facility

Rural Health Clinic

Single Specialty Group

Health Dept.

Federally Qualified Health Center

Mult. Specialty Group

Practice Type:

Private

Non-profit

Public

Other Practice Type:

Additional Comments:

Community Information

Community we'll be recruiting for:

Community Population:

HPSA?:

Yes

County:

County Population:

Average Housing Costs:

Major Businesses:

Schools (public and private):

Recreational Activities:

Nearest Metropolis:

Distance Away (in minutes):

Additional Comments:

By submitting this form, I understand that a placement fee will be assesses if a Physician, Nurse Practitioner or Physician's Assistant is successfully recruited by ORH for our organization.

Name:

Date: