Become an authorized practice activity site

Application to become an authorized competence phase practice activity site.

Practice Site Description * Required
Practice Site Description: Other * Required
Site/Activity Name: * Required
Location: * Required
Interprofessional Team Members in this Activity: * Required

Please list specific names of preceptors who will be on site during the event.
What student professions are invited to participate in this activity? Please list all that apply. NOTE: Some professions require a specific preceptor be available (COP, COM, CON, etc.) to provide certain work – health screenings/education etc.
Professions that may participate: * Required
Day(s) of the event: * Required
Hours available to participate: * Required
Research Focus or Population(s) Served: * Required
Please describe the activity a student will complete in a few sentences: * Required
Contact person for students to schedule/reserve an appointment for participation:
Name * Required
First Last
Phone * Required
Email * Required
Thank you for hosting an IPE student and serving as an integral component in the Interprofessional Educational experience for our future health and science professionals! Please contact the Office of Interprofessional Education (OIPE) at ipe@uams.edu if you have questions about this form or about Competence phase practice expectations.

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