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Level of Participation Key
O-- Observed Preceptor
D-- Direct Supervision
C-- Consulted with preceptor
EExperience
By signing here, I certify all the hours reported in clinical log is true and correct: ___________________________
Preceptor Signature
St. Thomas University
Advanced Family Practice Specialization
Student’s Clinical Log
Student Name: ______________________________________________ Student ID: __________________ Course Number: _____________________Semester/ Year: ________________
Preceptor/s Name: __________________________________ Faculty Name: __________________________Clinical Site Contact Info: Name/Number: __________________________
Clinical Site Address: ____________________________________________________________________ Total number of clinical hours needed: 125 Total clinic hours achieved: _______
Directions: Please include all information requested. Log are due on the designated time specified on your course syllabus. FORM MUST BE NEATLY PRINTED/TYPED
Date
Client
Age
Presenting Problem
Clinical Experience
Follow Up Plan
Level of
Student
Participation

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Level of Participation Key O-- Observed Preceptor D-- Direct Supervision C-- Consulted with preceptor E—Experience St. Thomas University Advanced Family Practice Specialization Student’s Clinical Log Student Name: ______________________________________________ Student ID: __________________ Cou ...
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