Clinical Preceptor Profile Update

Last Name: First Name: 
Home Address:
City: Zip: 
Home Phone : Home e-mail:
Facility Name:  Work Phone : 
Work e-mail: Work FAX:
Clinical Unit:  Shift: 
Routine Work Schedule: 
Unit Manager: Work Phone: 

I will participate in the clinical preceptorship and have reviewed the appropriate course objectives.

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.

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