Preceptor Qualification Record

 

Preceptor Name:

     


Georgia License Number

 
First Last Middle/Maiden  
         

Address:

       
 
Street City State Zip  
         

Current Employment:

     
 
Agency/Institution Location Health Care Setting Job Title  
         

Contact Information

     
   
Phone Number Email      
         
Have you been employed as an RN at least one year in the above setting? Yes / No
         

 

Student's Name:

Class Information:

Semester Course Number
 
 
First Last  
         

 

 

Education/Certification:

Please list professional education/national certification in chronological order:

Name of Institution Location

Diploma/Degree/
National Certification

Year Granted Major Field

 

 

CONSENT TO SERVE AS A PRECEPTOR

I have agreed to serve as a preceptor for a BSN senior student. The responsibilities and roles of this position have been explained to me. I understand that faculty may not be present on-site while students are in the clinical area, but they will be accessible by telephone. I also understand I have open access to the Department of Nursing for consultation and to all library privileges during the semester. I agree in this capacity.


By typing your full name in the field below, you agree to the above statement and it will serve as your signature: