School of Nursing
Graduate Preceptor Agreement Form
Student Name: _________________________________________________________________________________
EID: _____________________________ What unit will you be working on: _______________________________
D
ay of week at site: _________________ Anticipated duration of clinical experience: _______________________
Preceptor or Office Manager to fill out only:
I, ________________________________________________________________________ (preceptor name)
agree to precept _____________________________________________________________ (student name)
Preceptor signature: _______________________________________________________________
Michigan RN & NP License Number: ___________________________________________________
Expiration Date (s): ______________________ APN Certification Specialty: __________________
Certifying Body (ANCC or AANP): _____________________________________________________
Michigan MD or DO License Number: ____________________________________
Expiration Date: ____________________ Specialty Board Certification: _____________________
Number of students precepted concurrently with this applicant: ____________________________
Years in role: _________________
The following items are required to be on file for accreditation purposes:
o CV/Resume
o Copy of highest degree
o State Medical License
o Board Certification (MD, DO, NP, CNS & PA)
Please submit these documents to Deanna Kowaleski: dkowales@emich.edu
Students: Please submit both preceptor forms into Project Concert or by email to Deanna Kowaleski.
If you have any questions, please contact Deanna Kowaleski at dkowales@emich.edu or by calling: 734-487-
6599.
To be filled out by EMU only:
Is affiliation agreement in place: _______ yes _______ pending
_______ approved _______ denied By: ______________________________________________
Date: ____________________
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signature
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