Clinical Preceptor Profile & Application
Last Name:
First Name:
SS #
or
RN License #:
Home Address:
City:
Zip:
Home Phone :
Home e-mail:
Work Facility Name:
Work Phone:
Work e-mail:
Work FAX:
Clinical Unit:
Shift:
Unit Manager:
Manager Work Phone:
Routine Work Schedule:
Past Clinical Practice Experience:
Current Clinical Practice Responsibilities:
Personal Philosophy of Health Care:
I am available to participate in the clinical preceptorship on the following dates:
I have completed the On-Line Preceptor Orientation.
I understand & agree to follow the
principles
,
guidelines
and
responsibilities
for the precepted clinical experience(s).
Complete this form and print out a copy to be given to the Instructor/Coordinator at your college. The completed form will not automatically be forwarded to you college.
Back to Orientation