Fillable PRECEPTORSHIP FORM patient care as a nurse practitioner

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PRECEPTORSHIP FORM patient care as a nurse practitioner

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PRECEPTOR 10.12.2020 WWW.AANPCERT.ORG
1
AMERICAN ACADEMY OF NURSE PRACTITIONERS CERTIFICATION BOARD - PRECEPTORSHIP
PRECEPTORSHIP FORM
• Precepting advanced practice students during the provision of direct clinical supervision of
patient care as a nurse practitioner is consistent with the demonstration of continuing competence
and ongoing professional development.
• Formal Inter-Professional Education (IPE) programs organized in collaboration with nursing, physician assistant, medicine,
dentistry, or pharmacy Program Faculty and clinical sites are recognized by AANPCB.
• National organizations (e.g., the National Academy of Medicine, formerly called the Institute of Medicine) have identified team-based
care as a critical component of healthcare improvement. Joint accreditation activities of interprofessional collaboration help to promote
healthcare delivery and outcomes improvement.
Criteria for Claiming Preceptorship Clinical Practice Hours
• A maximum of 120 Preceptorship Clinical Practice Hours within the 5-year period
of certification may be claimed for a maximum of 25 non-pharmacology CE credits.
• Complete preceptor site information for each practice site is required.
• Faculty Coordinator contact information is required.
• AANPCB reserves the right to request additional supporting documentation for validation
of preceptorship.
Application
• Submission of a complete Preceptorship Form is required for recertification.
• Complete as many forms as necessary to account for preceptorship sites and students.
• Upload completed forms to My Documents in your My AANPCB account online. Copies
may also be emailed or faxed as a PDF.
• Incomplete forms will not be processed.
Conversion of Preceptor Hours into CE Credits
• A maximum of 120 Preceptorship Clinical Practice Hours within the 5-year period of
certification may be claimed for a maximum of 25 non-pharmacology CE credits.
• Convert the number of hours precepted to CE credits using the Conversion Table.
• Record the total number (not to exceed 25) of non-pharmacology credits on the CE Log
of the renewal application.
• Calculation of 120 clinical hours is based on precepting 8 hours per week for one
semester (i.e., 15 weeks x 8 hours/week = 120 hours).
PRECEPTOR HOURS
CONVERSION TABLE
CLINICAL
HOURS
CE
CREDIT
1 – 5 hours
= 1 CE
6 – 10 hours
= 2 CE
11 – 15 hours
= 3 CE
16 – 20 hours
= 4 CE
21 – 25 hours
= 5 CE
26 – 30 hours
= 6 CE
31 – 35 hours
= 7 CE
36 – 40 hours
= 8 CE
41 – 45 hours
= 9 CE
46 – 50 hours
= 10 CE
51 – 55 hours
= 11 CE
56 – 60 hours
= 12 CE
61 – 65 hours
= 13 CE
66 – 70 hours
= 14 CE
71 – 75 hours
= 15 CE
76 – 80 hours
= 16 CE
81 – 85 hours
= 17 CE
86 – 90 hours
= 18 CE
91 – 95 hours
= 19 CE
96 – 100 hours
= 20 CE
101 – 105 hours
= 21 CE
106 – 110 hours
= 22 CE
111 – 115 hours
= 23 CE
116 – 119 hours
= 24 CE
120+ hours
= 25 CE
PRECEPTOR 10.12.2020 WWW.AANPCERT.ORG
2
AMERICAN ACADEMY OF NURSE PRACTITIONERS CERTIFICATION BOARD - PRECEPTORSHIP
PRECEPTORSHIP FORM Print as many copies of this CE Log as needed to complete application.
NP Certificant Name
(First Middle Last)
Last 4 of SSN
AANPCB Certification Number
(begins with A, E, F, G, or AG)
Begin Date:
(mm/dd/yyyy)
End Date:
(mm/dd/yyyy)
Preceptorship Date (s)
Specialty /Population Focus
Total # Preceptorship Hours completed =
(Maximum 120 hours)
Converted to CE Hours =
(maximum 25 Non-Pharmacology hours)
The preceptorship was conducted with advanced practice provider students enrolled in:
APRN Program
Interprofessional Educational (IPE) Program
□ Nurse Practitioner
□ Nurse Anesthetist
□ Medicine
□ Physician Assistant
□ Nurse Midwife
□ Clinical Nurse Specialist
□ Pharmacy
□ Other:
Number of Students Precepted
Preceptor Practice Site
Address
City, State, Zip
Educational Institution/ Program
Educational Address
Faculty
Coordinator
Name & Credentials
Email
Phone
Number
Preceptorship Date (s)
Specialty /Population Focus
Total # Preceptorship Hours completed =
(Maximum 120 hours)
Converted to CE Hours =
(maximum 25 Non-Pharmacology hours)
The preceptorship was conducted with advanced practice provider students enrolled in:
APRN Program
Interprofessional Educational (IPE) Program
□ Nurse Practitioner
□ Nurse Anesthetist
□ Medicine
□ Physician Assistant
□ Nurse Midwife
□ Clinical Nurse Specialist
□ Pharmacy
□ Other:
Number of Students Precepted
Preceptor Practice Site
Address
City, State, Zip
Educational Institution/ Program
Educational Address
Faculty
Coordinator
Name & Credentials
Email
Phone
Number
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Completed 10 May 2021

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