Preceptor Faculty Survey

1. First name: 2. Last name:
3. Email address:
4. Do you wish to participate as a Preceptor AAPS mentor? Yes | No

If yes, please complete the following:
5. Office Phone no. Cell Phone no.
6. Preferred method of correspondence: email | office phone | cell phone
7. Coordinator Information
First Name:

Email Address:
Last Name:

Phone no.
8. Present Institution

Academic appointment:
Date Started:
9. Clinical Focus:
10. Research Focus
Investigative interests: Clinical:

Investigative interests: Basic Science:
11. Please list specific areas in which you would like to mentor someone outside of your institution:

American Association of Plastic Surgeons
500 Cummings Center, Suite 4400, Beverly, MA 01915
Phone: 978-927-8330 | Fax: 978-524-0498