Fillable Clinical Agency And Preceptor Form 2019

Fill Online, Printable, Fillable, Blank Clinical Agency And Preceptor Form 2019 Form

Use Fill to complete blank online WILKES UNIVERSITY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Clinical Agency And Preceptor Form 2019

On average this form takes 9 minutes to complete

The Clinical Agency And Preceptor Form 2019 form is 2 pages long and contains:

  • 1 signature
  • 0 check-boxes
  • 33 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Wilkes University

BROWSE WILKES UNIVERSITY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Clinical Agency and Preceptor/Mentor Form
This form is to be completed electronically and emailed to the appropriate reference as outlined
below. HANDWRITTEN FORMS WILL NOT BE ACCEPTED.
Copies of required preceptor/mentor information (license, certification, CV) MUST
accompany this form for final approval of the clinical experience and development of the
clinical affiliation agreement. PLEASE SEND THE FORM AND ALL OTHER
REQUIRED DOCUMENTS IN ONE EMAIL TO THE FOLLOWING:
Nurse Executive, Nursing Education, and Nursing Informatics Students: Please submit to
lori.novitski@wilkes.edu
DNP Students: Please submit to lori.novitski@wilkes.edu
NSG 411 Students: Please submit to lori.novitski@wilkes.edu , Graduate Clinical Coordinator
.
Nurse Practitioner RN to M.S.N, M.S.N and Post Graduate/APRN Certificate Students:
Please submit to lori.novitski@wilkes.edu , Graduate Clinical Coordinator
Student and Course Information
Name:
Telephone Number:
Course Start Date (Month):
Year:
Course: NSG
Is your preceptor/mentor and agency information the same as from a previous clinical course?
If yes, complete the following and forward this form as instructed above.
Clinical Course: NSG ______
Course Start Date (Month):
Year:
If no, complete the preceptor/mentor and agency information below and forward this form as
instructed above.
Preceptor/Mentor Information
Name:
Title:
Discipline:
Type(s) of patients seen:
Will the preceptor/mentor be supervising other students
concurrently?
Address:
Phone:
Address:
Fax:
City, State, Zip:
Email:
Agency Information
Name:
Setting*: * Hospital, physician office, outpatient
clinic, etc.
Street Address:
Contact Person for Agency Responsible
for Contract Completion (this may be a
different person than the preceptor):
City, State, Zip:
Contact Person Title:
Contact Person Phone:
Contact Person Email:
Are you employed by the agency above:
If using more than one preceptor per clinical course, a separate form must be submitted
for each.
Review and Approval by Passan School of Nursing Designee (Print)
_________________________________________________________
Reiview and Approval by Passan School of Nursing Designee (Signature)
__________________________________________________________
Date
__________________________
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Clinical Agency And Preceptor Form 2019

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 19 February 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document