Thank you for agreeing to be a clinical supervisor for a JCU Nurse Practitioner student. Please complete the following details, sign
and return to the Nurse Practitioner student applicant for submission to JCU.
1. JCU Student Applicant Name
2. Clinical Supervisor Title &
Full Name
3. Email
4. Telephone
5. Health Facility
6. Current AHPRA Registration
NB: JCU will conduct AHPRA
registration search)
Medical Practitioner Nurse Practitioner
7. Current Position
8. Qualifications
9. Current Responsibilities
10. Work History
Please list previous posts
teaching and clinical)
11. Other Relevant Information
12. Model of Clinical Supervision
As the Clinical Supervisor of the Nurse Practitioner student you will be expected to
support them through their studies. This includes observing and assessing their
clinical practice on a regular basis, discussing strengths and weaknesses and offering
suggestions for development and/or modification of practice and attitudes. In addition
to the regular supervisory contact, it is expected supervisors and students would meet
on a fortnightly basis at a minimum. The types of activities that may occur during this
time include the presentation of cases (both long and short), the formulation of
development plans, completion of progress and assessment forms and general
support for the student as they explore what will be new professional territory. You
will also be required to offer suggestions and support the student Nurse Practitioner in
their role development and other professional experiences throughout their studies.
Signature: Date:
___________________________________________________ ______________________________