TTU Nursing Graduate Programs
Preceptor Intent Form
Student Name: Course:
Tnumber: Date:
TTU E-mail:
Instructions: The preceptor intent form is a tool created for faculty to assess the preceptor’s ability
to meet the practicum course’s population focus and learning outcomes for the student. Please
complete the student and preceptor sections of this form.
Student Section
Semester:
Fall
Spring
Summer
Year:
Are you employed by this agency?
Yes No
Have you precepted at the graduate
level with this preceptor/agency
before?
Yes No
If yes, for which course?
How many hours do you plan to
complete with this preceptor?
If you will be using an additional
preceptor for the same course, please
explain below.
Agency Section
Agency/Clinic Name:
If this agency is part of a corporation or is legally known by another name, please
provide this information:
Agency/Clinic Street Address:
Agency/Clinic City:
Agency/Clinic State:
Agency/Clinic Zip:
Agency/Clinic Telephone:
Agency/Clinic Fax:
Name of the contact person for clinical agreements/office manager/Human Resources
representative who may be assisting with this agreement:
Direct Email Address for above contact:
Preceptor Section
Preceptor's Full Name:
Preceptor’s credentials (i.e., FNP, ANP,
MD, etc.):
Preceptors Email Address:
Degree #1: Degree Type
Degree #1: Degree School
Degree #1: Year Received
Degree #2: Degree Type
Degree #2: Degree School
Degree #2: Year Received
Degree #3: Degree Type
Degree #3: Degree School
Degree #3: Year Received
Professional License #1: Number
Professional License #1: State
Professional License #1: Expiration Date
Professional License #2: Number
Professional License #2: State
Professional License #2: Expiration Date
Professional Certification #1: Number
Professional Certification #1: Expiration
Date
Professional Certification #2: Number
Professional Certification #2: Expiration
Date
Do you see children at your
practice/clinical site?
Yes No
If yes, what percentage of your patients
are children?
If yes, what is the average number of
children seen per day?
Do you see adolescents at your
practice/clinical site?
Yes No
If yes, what percentage of your patients
are adolescents?
If yes, what is the average number of
adolescents seen per day?
Do you see women at your
practice/clinical site?
Yes No
If yes, what percentage of your patients
are women?
If yes, what is the average number of
women seen per day?
Do you see Adults at your
practice/clinical site?
Yes No
If yes, what percentage of your patients
are adults?
If yes, what is the average number of
adults seen per day?
Do you see Older Adults/Geriatrics at
your practice/clinical site?
Yes No
If yes, what percentage of your patients
are older adults/geriatrics?
If yes, what is the average number of
older adults seen per day?
Student Responsibilities
Note: This information is only a summary of responsibilities for the student. The Student Handbook and
policies described in this document are the official references for students regarding clinical
requirements and contain additional important information.
It is the responsibility of the student to:
o Follow the NP Clinical Placement Guidelines for Students, Preceptors, & Faculty.
o Abide by TTU and School of Nursing policies as identified in the Student Handbook.
o Abide by all clinical agency policies and procedures.
o Complete all necessary paperwork prior to entering the clinical site.
o Exchange direct contact information with the preceptor.
o Develop personal learning objectives for each practicum course.
o Provide preceptor with copies of
· course syllabus (course objectives, student learning outcomes, and faculty contact
information);
· personal learning objectives;
· course skills list (if required by course).
o Develop a Clinical Rotation Plan as described above with the preceptor and submit the
document to the appropriate course Dropbox.
o Be prepared to work the day(s) and hours of the preceptor and as agreed upon per the
Clinical Rotation Plan.
o Request feedback from your preceptor on a regular basis, including review of the mid-
semester and final evaluations.
o Maintain appropriate clinical logs as described above.
o Notify the clinical faculty and Clinical Placement Coordinator as early as possible of any
difficulties experienced in the clinical rotation.
o Communicate regularly with your faculty member keeping them apprised of your clinical
experiences and progress in meeting the clinical course objectives and competencies.
o Send preceptor a formal thank-you note or letter.
Preceptor Responsibilities
It is the responsibility of the preceptor to:
o Provide licensure and other documentation as required during the preceptor approval
process.
o Exchange direct contact information with the student.
o Complete the Clinical Rotation Plan with the student.
o Orient the student to the office and clinic facilities (e.g. staff members, policies, attire,
protocols, patient flow, records/documentation, requisitions, accessing other departments,
communications, preceptor practice preferences and expectations).
o Demonstrate professional role-modeling.
o Provide the student with access to patient clinical records, documentation, and electronic
health records systems if available.
o Explain to the student your organization, prioritization, patient evaluation, exam,
diagnostic decisions, management, patient education, and follow-up for patients.
o Discuss expectations and parameters for practice with the student. Be direct about what
you want relative to patient flow, sharing in the management of visits, and documentation.
Students are limited to observation to the first 1-2 days after which the student should begin
seeing a few patients in a dependent clinical role. Over the next several clinical
days/weeks, the student should become increasingly independent, but always with
preceptor oversight of student practice.
o Assist the student with the selection/inclusion of appropriate and increasingly challenging
learning experiences.
o Be available to consult with the student or to assume responsibility for care as needed.
o Encourage and expect the student to become increasingly more responsible, pro-active, and
self-reliant during the semester.
o Review clinical experiences daily and approve or reject.
o Document any learning deficiencies or clinical performance issues as they occur.
o Provide constructive feedback to the student via formative assessment.
o Review the evaluation criteria on the Midterm/Final Preceptor Evaluation of NP Student.
o Address conflicts or concerns with the student as early as possible, clarifying your
expectations and identifying solutions or necessary adjustments.
o Notify any student who is in jeopardy of failure no later than mid-point of the clinical
practicum.
o Notify clinical faculty and course coordinator if student performance is substandard, failing,
or if there are any other clinical or professional problems or concerns.
o Complete the mid-term preceptor evaluation.
o Complete the final preceptor evaluation.
I agree (Student)
Student Signature:
Date:
I agree (Preceptor)
Preceptor Signature:
Date: