The University of Chicago - Celiac Disease Center

* First Name * Last Name

* Street Street (cont.) * City * State * Zip * Office Phone * Mobile Phone * Pager * Fax * E-mail

* Please select which course you are applying for:

* Primary Care Physician? Yes No

* If Yes, Choose: Other * Number of year in practice

* Gastroenterologist? Yes No

* If Yes, Choose: Other * Number of year in practice

* Nurse Practitioner? Yes No

* If Yes, Choose: Other * Number of year in practice

* Dietitian? Yes No

* If Yes, Choose: Other * Number of year in practice

* GI Fellow? Yes No

* If Yes, Number of year in practice * Program Director Name * Program Director Email * Program Director Phone

* Other? Yes No

* Please Describe:

* How many physicians are in your practice? * How many dietitians are in your practice? * How many nurse practitioners are in your practice? * How many patients are seen on average in your practice per week? * How many of your patients are pediatric (1-17 years old)? * How many of your patients are adult (above 18)?

* Name * Street Street (cont.) * City * State * Zip * Phone * Website

* Check all that apply:

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

District Of Columbia

Florida

Georgia

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

North Carolina

North Dakota

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Washington

West Virginia

Wisconsin

Wyoming

* Have you had any additional training in celiac disease? Yes No

If yes, Type and duration of training and institution:

* How many new celiac patients do you see in one month? * How many celiac patients in total are followed in your practice? * How far are you from the nearest tertiary center for referrals of celiac patients? * Name of Center

* How did you hear about The University of Chicago Celiac Disease Center?

What is your primary reason for committing to additional training?

A Current CV A letter of support from supervisor or colleague OR Personal Statement

Preceptorship Application

Office Mailing Address

Are you a:

What is the complete name and address of your primary hospital?

Please select States in which you are licensed to practice

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