Physician Assistant Program

Name:

E-mail:

Practice Specialty:

Practice Name:

Practice Address:

Practice City:

Practice State:

Practice Zipcode:

Practice Phone Number:

Home Phone Number:

Cell Phone Number:

I am interested in supporting the PA Program by:

Mentoring a first year student

Precepting a second year student

Serving on a committee

Giving a lecture

Helping with physical examination class or lab

Proctoring clinical examinations

Becoming a small group facilitator

If you checked lecture above, which topic areas?:

If you checked serve on a committee, which one?:

Admissions Committee

Curriculum Committee

Progress & Promotions Committee

Additional Comments:

What is the best way to contact you?:

Email

Work Phone

Home Phone

Cell Phone

OHSU — Oregon Health & Science University