Graduate Preceptor Agreement and Qualification - Wellstar College of Health and Human Services

Graduate Nursing Placement for Preceptors

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

Preceptor Name:

*First Name

*Last Name

*Middle/Maiden

*License Number

*Board & Certification Number

*NPI Number

Current Practice Address:

*Street

*City

*State

*Zip

Employment History:

*Current Practice Type (Rural, Family, Specialty, etc.)

*Population Served

*Total Years employed in role

Previously Precepted Graduate Nursing Students?

Practice Type (Rural, Family, Specialty, etc.)

Population Served

Practice Type (Rural, Family, Specialty, etc.)

Population Served

Contact Information:

*Phone Number

*Email

*Have you been employed in your role at least one year in the above setting?

YesNo

Student's Name and Class Information:

Student's Name

*Semester

Education/Certification:

*Institution, Location, Diploma/Degree/National Certification

CONSENT TO SERVE AS A PRECEPTOR

I have received a copy of the Preceptor Manual and agree to precept a KSU graduate nursing student.

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

*Signature