Preceptor Grant Application

STATE OF ARIZONA - GRANT PROGRAM FOR PRECEPTORS OF HEALTHCARE GRADUATE STUDENTS
Preceptor Eligibility: an allopathic physician, an osteopathic physician, a certified nurse midwife, a certified registered nurse anesthetist, a clinical nurse specialist, a registered nurse practitioner, a physician assistant or a dentist who is licensed pursuant to Arizona Revised Statutes, Title 32 and who serves as volunteer preceptors for a minimum of 4 weeks for a preceptorship of a graduate student studying in Arizona, may apply for a grant from the statewide nonprofit organization that represents their discipline and that is allocated grant monies.

Award Amount: Preceptors are limited to a grant of $1,000 (one thousand dollars) grant per state fiscal year (July 1 - June 30) regardless of the number of preceptorships the applicant provides in that year.

Preceptor Applicant Instructions: Submit one application per state fiscal year (July 1 - June 30). Include all graduate student names of preceptorships covered. Please email info@aznurse for questions. If you need to list further institutions and/or students, email that information to info@aznurse.org and staff will append to your application.
Name*

First NameLast Name
Credentials*
NPI
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address of Record for Preceptor's license*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the address to mail grant payment different from your address of record above?

YesNo
Address to mail grant payment (if different from Address of Record above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
This grant is considered taxable income by the IRS.

IRS requirements for a 501(c)6 tax exempt organizations require that merit-based grants over $600 per tax year be issued a 1099-MISC at the conclusion of the tax year.

To facilitate this process, upload a current W-9 for the grant recipient entered above.

Please ensure you sign your form. Signature line is found 2/3 of the way down the page. W-9s are only complete if signed.

>> More Information and W-9 forms can be found the IRS website. <<
Upload a current W-9 for the grant recipient entered above*

Cancelof
Indicate Your Licensed Professional Discipline*

Certified Nurse Midwife (CNM) -Advanced Practice Registered Nurse (APRN)Certified Registered Nurse Anesthetist (CRNA) - Advanced Practice Registered Nurse (APRN)Clinical Nurse Specialist (CNS) - Advanced Practice Registered Nurse (APRN)Registered Nurse Practitioner (NP) - Advanced Practice Registered Nurse (APRN)
Preceptor's Arizona License Number*
Specialty/Focus/Certification
Healthcare Organization/Site Where Preceptorship Took Place:
Site 1 Name:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Site 2 Name (if applicable):
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Organization (Select all that apply)*

Acute CareHome CarePrimary CareFederally Qualified Health CenterSkilled Nursing Facility (SNF)Rehabilitation CenterCommunity HealthAmbulatory CareOutpatient CenterCritical AccessOther
Is the healthcare organization located in an urban or rural area according to ARS 36-2171?

*Based on the 2020 Decennial US Census, all locations in counties besides Maricopa, Pima, and Pinal are considered rural.

If within Maricopa, Pima and Pinal, your organization address needs to be assessed at the Census County Division (CCD), and will be considered rural if they met requirement (b) located in a CCD with less than fifty thousand persons. https://censusreporter.org/
UrbanRural
Patient Population or clinical specialty addressed (Select ALL that apply)*

Med-surgCritical CareOBPedsNeonatalPerioperativeGeriatricBehavioral HealthPrimary CareOutpatientLong-term CareRehabHome CareOther
STUDENT #1:
Setting for Preceptorship (OTC, private practice, etc): *
Student Precepted:*

First NameLast Name
Name of educational institution/program or residency AND location of student/graduate:*

Educational Institution/ProgramCity, State
Confirmatory Agreement or Other Verification of Student Program Enrollment*

Cancelof
Dates of Preceptorship*

MonthDayYear
Start
MonthDayYear
End
Provide a brief description (1 to 2 sentences) of the learning that took place during this preceptorship:*
STUDENT #2 (if applicable):
Setting for Preceptorship (OTC, private practice, etc):
Student Precepted:

First NameLast Name
Name of educational institution/program or residency AND location of student/graduate:

Educational Institution/ProgramCity, State
Confirmatory Agreement or Other Verification of Student Program Enrollment

Cancelof
Dates of Preceptorship

MonthDayYear
Start
MonthDayYear
End
Provide a brief description (1 to 2 sentences) of the learning that took place during this preceptorship:
STUDENT #3 (if applicable):
Setting for Preceptorship (OTC, private practice, etc):
Student Precepted:

First NameLast Name
Name of educational institution/program or residency AND location of student/graduate:

Educational Institution/ProgramCity, State
Confirmatory Agreement or Other Verification of Student Program Enrollment

Cancelof
Dates of Preceptorship

MonthDayYear
Start
MonthDayYear
End
Provide a brief description (1 to 2 sentences) of the learning that took place during this preceptorship:
If there are additional students, please send information to info@aznurse.org
ATTESTATION:
I have read and completed this application and attest that its contents are true and correct.*

Clear
Type Name
Date*

MonthDayYear
Date
Should be Empty:

STATE OF ARIZONA - GRANT PROGRAM FOR PRECEPTORS OF HEALTHCARE GRADUATE STUDENTS