Preceptor Qualification Record - Wellstar College of Health and Human Services

Record Nursing Preceptor Qualifications

If you see this don't fill out this input box.

Preceptor Name:

*First Name

*Last Name

*Middle/Maiden

*Georgia License Number

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?

YesNo

Student's Name and Class Information:

*Student's Name

First, Last

Semester

*Course Number

Education/Certification:

*Institution, Location, Diploma/Degree/National Certification

Please list professional education/national certification in chronological order:

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:

*Signature