Preceptor Information Form

Nurse Practitioner Program Preceptor Information Form
To be completed by the identified NP student preceptor. The information on this form will be used to verify your NP/MD/DO credentials and approve you as a preceptor.

Thank you!
Preceptor Information
Approved By:
Name:*
Email Address:*
Cell Phone:*
Fax:
Practice Site Information
Practice Site Name:*
Practice Site Address*

Street Address

Street Address Line 2

CityState

Zip Code
Site Phone Number*
Fax:
Website:

Employment Information
Employment Status:*
Other (Please Specify):
Hospital(s) where you practice or have privileges (if applicable):
Clinical Hours (on average per week):
Providing Health Care:
Precepting APRN Students:
Precepting any type of student:
Are you affiliated with a Provider Group?*
*If your liability insurance is covered by the Provider Group, the University will need to establish a contract with the group.*
Provide the name, phone number and email address for the Provider Group who can assist with establishing an Affiliation Agreement.
Student Name:*
My completion of this form certifies that I agree to precept the student entered above.
My preceptorship will
start on

MonthDayYear
Date
and end on

MonthDayYear
Date
As lead preceptor, I also agree to complete all evaluations of this student and if supervision is delegated to another preceptor in my organization, that preceptor will have the qualifications required.
Signature (type full name):*
Date:*

MonthDayYear
Date
Should be Empty: