Preceptor Packet
  
 
CLAREDON COLLEGE HEALTH CENTER
School of Nursing
Preceptor Information


Circle: CNA Program                               CNA to RN Program

Name: _________________________________________________________
License Number: ___________________
Position/Title: ____________________________________________________ Contact information:
Present Employment (organization/hospital and department/unit): __________________________
Site Name: __________________________________
Employer’s Address and Phone Number:                                                                                   
Address: ____________________________________
                ____________________________________
Telephone Number:  _________________ Work _________________ Home _________________ Cell
E-mail Address ________________________________
EDUCATION:
Degree                                  Year                                               School/Program Address
__________                _____________                       ____________________________________________
Experiences Available (Please check all applicable)
Acute Care               Long Term Care               Rehab                    Other
Certifications                                 Years of Practice                                      Cert. Exp. Date ____________________              _____________                                       ____________________
Licensure no. ___________________________  Expiration Date: _________
Do you have malpractice insurance? Yes_______________ No________________
Course No: ______________
Semester/Trimester: Fall ( ) Spring ( ) Summer ( ) Year: _________ Date: ______________








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Student-Faculty-Preceptor Agreement Form
 
COURSE:  ______________________________________
PRECEPTOR: ____________________________________
STUDENT: ______________________________________
SITE NAME OR AGENCY ________________________________________
SITE or AGENCY ADDRESS ______________________________________
                                               ______________________________________
I agree to act as a Clinical Preceptor for the above named student.  
______________________________________________________________________________ Signature                                                                                                    Date
Faculty Name: _____________________________________
Course No: ______________
Student signature: ___________________________   Date signed:  ____________________________
Faculty signature:  ___________________________    Date signed:  ____________________________
Preceptor signature:  __________________________  Date signed:  ____________________________
 
Please contact the Instructor below if you have any questions at any time: ____________________________________________________________ Phone Number
____________________________________________________________ Email Address