Preceptor Agreement Form Deadlines: Fall Semester. – Due May 15th Spring Semester – Due October 15th Summer Session – Due March 15thPreceptor Agreement • April 1st, 2022
Preceptor Name: _______________________________________ Highest Degree: ___________________________ Preceptor Phone: ____________________ Preceptor Email: ____________________________________________ Preceptor Prof. License #: _________________________________ Type of License: ___________________________ Licensing Agency: ______________________ Issuing State: _____ Expiration Date: ___________________________ Does preceptor have at least 2 years of relevant preceptor experience? Yes ☐ No☐ List relevant experience pertaining to student’s area of focus: (i.e. Leadership, management, policy, Peds, NP, women’s health, gero) _______________________________________________________________________________________________ Areas of Certification: ____________________________________________________________________________ Is Preceptor the Student’s Direct Supervisor at work (student’s place of employment)? Yes ☐ No☐ Has the Preceptor previously precepted for Mennonite College of Nursing studen
Preceptor Agreement Between thePreceptor Agreement • March 12th, 2021
Preceptor Agreement BetweenPreceptor Agreement • April 18th, 2022
This Agreement outlines responsibilities of the above parties when supervising and educating assigned Family Nurse Practitioner (FNP), Psychiatric Mental Health Nurse Practitioner (PMHNP), Nurse Leadership, and Nurse Administration students during the clinical rotation experience.
SAN FRANCISCO FIRE DEPARTMENT PARAMEDIC FIELD PRECEPTOR AGREEMENTPreceptor Agreement • April 14th, 2016
This agreement is made and entered into June 1, 2016 by and between the San Francisco Fire Department (hereinafter referred to as “DEPARTMENT”), and Las Positas College, Las Positas Paramedic Program; of 3000 Campus Hill Drive Livermore CA 94551- 7623 PH 925.424.1000 (herein referred to as “AGENCY”)
Undergraduate Nursing Program Preceptor AgreementPreceptor Agreement • August 9th, 2021
Preceptors for the undergraduate nursing program are chosen in collaboration with the clinical facility’s management and leadership team. Each preceptor must have a minimum of 3-years nursing experience as a registered nurse and an unencumbered RN license within the state in which they will be assigned.
PRECEPTOR AGREEMENTPreceptor Agreement • May 15th, 2018
Undergraduate Nursing Program Preceptor AgreementPreceptor Agreement • September 1st, 2023
Preceptors for the undergraduate nursing program are chosen in collaboration with the clinical facility’s management and leadership team. Each preceptor must have a minimum of 18 months nursing experience as a registered nurse and an unencumbered RN license within the state in which they will be assigned.
School of Nursing Graduate Preceptor Agreement FormPreceptor Agreement • February 18th, 2019
Preceptor AgreementPreceptor Agreement • April 6th, 2023
By signing your name below, you are confirming that you have read and understand the conditions and the requirements of a Paramedic Preceptor for Columbia State Community College as outlined in the following documents:
DEPARTMENT FOR PUBLIC HEALTH PRECEPTOR AGREEMENT (TEMPLATE)Preceptor Agreement • April 12th, 2022
The preceptorship is an essential component of the physical assessment continuing education courses being sponsored by the Department for Public Health for registered nurses. Continuing education courses requiring a formal preceptorship include the STI Enhanced Role Registered Nurse and the STI Intensive training.
Preceptor Agreement BetweenPreceptor Agreement • May 7th, 2020
This Agreement outlines responsibilities of the above parties when supervising and educating assigned Physician Assistant (PA) students during the clinical rotation experience.
PRECEPTOR AGREEMENT FORMPreceptor Agreement • July 20th, 2015
Form Instructions: Student will complete the first page. Preceptor will complete and sign the second page. The completed form should be returned to the clinical faculty (by the student) for final signature.
PRECEPTOR AGREEMENT FORMPreceptor Agreement • July 20th, 2015
Form Instructions: Student will complete the first page. Preceptor will complete and sign the second page. The completed form should be returned to the clinical faculty (by the student) for final signature.
Preceptor Agreement FormPreceptor Agreement • June 29th, 2024
Dear distinguished colleague, we really appreciate and express our gratitude for accepting the responsibility of instructing our students throughout the mandatory summer training time. We commend your diligent oversight of them throughout the training time. To familiarize yourself with the responsibilities expected of you throughout the training time, please scan the enclosed barcode to access the duties assigned to the trainer pharmacist.
School of Nursing Graduate Preceptor Agreement FormPreceptor Agreement • February 18th, 2019
PRECEPTOR AGREEMENT FORMPreceptor Agreement • July 20th, 2015
Form Instructions: Student will complete the first page. Preceptor will complete and sign the second page. The completed form should be returned to the clinical faculty (by the student) for final signature.
Graduate Program-NP TrackPreceptor Agreement • January 25th, 2021
Thank you for your willingness to share your time and expertise. Please take a moment to provide the following information so we can work with you in a way most convenient for you.
PRECEPTOR AGREEMENT FORMPreceptor Agreement • July 20th, 2015
Form Instructions: Student will complete the first page. Preceptor will complete and sign the second page. The completed form should be returned to the clinical faculty (by the student) for final signature.
Preceptor Agreement Form Deadlines: Fall Semester. – Due May 15th Spring Semester – Due October 15th Summer Session – Due March 15thPreceptor Agreement • June 7th, 2022
Preceptor Name: _______________________________________ Highest Degree: ___________________________ Preceptor Phone: ____________________ Preceptor Email: ____________________________________________ Preceptor Prof. License #: _________________________________ Type of License: ___________________________ Licensing Agency: ______________________ Issuing State: _____ Expiration Date: ___________________________ Does preceptor have at least 2 years of relevant preceptor experience? Yes ☐ No☐ List relevant experience pertaining to student’s area of focus: (i.e. Leadership, management, policy, Peds, NP, women’s health, gero) _______________________________________________________________________________________________ Areas of Certification: ____________________________________________________________________________ Is Preceptor the Student’s Direct Supervisor at work (student’s place of employment)? Yes ☐ No☐ Has the Preceptor previously precepted for Mennonite College of Nursing studen
APPLICANT INSTRUCTIONSPreceptor Agreement • February 7th, 2023
Faipllpoliucat trioenqufoirreAdpipnlfioerdmNautitorintiobnel–owDieptreiotircsaesmkinpghaasipsrionsDpeICcAtiSv.e preceptor to sign. Signed form must be submitted with
PRECEPTOR AGREEMENT AND CREDENTIALSPreceptor Agreement • July 27th, 2017
Preceptor: Please fill out Parts A & B of the Preceptor Agreement form. Sign and return to student of requesting faculty member. Clinical affiliation agreements and preceptor agreements must be in place prior to the student being on site for clinicals.
Preceptor agreement form Gulf Coast Dietetic InternshipPreceptor Agreement • May 16th, 2016
Preceptor Agreement FormPreceptor Agreement • July 20th, 2009
Preceptor Agreement 2025-2026Preceptor Agreement • October 2nd, 2024
Fill out the required information below. Signed form must be submitted with application in DICAS. For the 2025-2026 cohort, students will complete:
T H E U N I V E R S I T Y O F B R I T I S H C O L U M B I APreceptor Agreement • January 31st, 2013
APPLICANT INSTRUCTIONSPreceptor Agreement • February 7th, 2023
Fill out required information below prior asking a prospective preceptor to sign. Signed form must be submitted with application for Applied Nutrition – Dietetics emphasis in DICAS.
Preceptor Agreement FormPreceptor Agreement • July 15th, 2010
The UAMS College of Pharmacy agrees to work closely with individual preceptors to support their needs as volunteer faculty members of the College. The Assistant Dean of Experiential Education will coordinate efforts for scheduling students each year and provide a direct link with the College and its resources (preceptor development training programs, on-line resources, and standard rotation manuals). If questions or concerns arise please contact Dr. Schwanda Flowers (501-686-7920). Please feel free to fax this form back to 501-686-8104.
University of Arizona Mel and Enid Zuckerman College of Public Health MASTER OF PUBLIC HEALTH PROGRAM Preceptor agreement FORM (To be provided by the student with their Internship Planning paperwork)Preceptor Agreement • March 26th, 2019
To be completed by the Preceptor/Site Supervisor: Note: At the discretion of the academic department, a formal letter of offer on organization letterhead or organizational email bearing supervisor's signature may be attached in lieu of this section. A detailed position description may also serve as useful documentation of expected activities and qualifications.
School of Nursing EMU Preceptor Agreement FormPreceptor Agreement • December 4th, 2023
Copy of highest degree Board Certification (MD, DO, NP, CNS, NP & PA) Please submit these documents to Dr. Vicki Washington - vwashing@emich.edu
Preceptor Agreement FormPreceptor Agreement • June 7th, 2022
Applicant Instructions: Fill out required information below prior asking a prospective preceptor to sign. Signed form must be submitted with application for PSM in Applied Nutrition – Dietetics emphasis in GradApp.
Preceptor AgreementPreceptor Agreement • July 25th, 2018
This completed form must be submitted 6 weeks prior to clinical rotation start date. The preceptor and site must be approved by USI prior to the start of clinical rotation.
PRECEPTOR AGREEMENT FORM-LEADERSHIP TRACKPreceptor Agreement • June 19th, 2019
I, (Printed name of Preceptor) have met with the graduate student regarding a preceptorship at this agency. I have reviewed the preceptorship agreement, and we have discussed the course objectives, clinical requirements, and the Doctor of Nursing Practice student evaluation document for the practicum courses. I agree to act as a Clinical Preceptor to ______________________________________RN (Printed name of Graduate Student) as part of his/her enrollment in the Holy Family University Graduate Nursing Program’s practicum course(s). I am aware that I will need to confer with the faculty during and at the end of the semester to provide any information that I believe is necessary regarding the student’s progress in the practicum. A written evaluation of the student on the provided form should be submitted at the end of the semester.
Preceptor Agreement FormPreceptor Agreement • October 20th, 2021
Preceptor AgreementPreceptor Agreement • April 4th, 2016
Please complete the top portion of this form and review the course requirements with your identified preceptor. Your preceptor must complete and sign this form. Documentation of the preceptor agreement is required for completion of Task 1 in the Field Experience Course. You will upload the completed and signed form in Taskstream.
Preceptor AgreementPreceptor Agreement • November 8th, 2020
This completed form must be submitted 6 weeks prior to clinical rotation start date. The preceptor and site must be approved by USI prior to the start of clinical rotation.
