Fillable Preceptor Verication & Self-Reection Form

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Preceptor Verication & Self-Reection Form

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The Preceptor Verication & Self-Reection Form form is 2 pages long and contains:

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Preceptor Verication & Self-Reection Form
Please briey describe what activities you engaged in to prepare for your role as a preceptor.
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How did serving as a preceptor impact your dietetics practice?
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What changes will you make in your future role as a preceptor as a result of this experience?
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Verication Statement
Preceptor Name:___________________________________________
(Please print)
Number of CPEUs to be Awarded:_________________________________
*Please refer to optional preceptor log form
1-25 Contact Hours 1 CPEU
26-50 Contact Hours 2 CPEUs
51 and greater Contact Hours 3 CPEUs
ACEND Accredited Program Director: ______________________________
(Please print)
Signature: ______________________________________________
Accredited Program Name: ____________________________________
Institution: ______________________________________________
Signature Date: ___________________________________________
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Preceptor Verication & Self-Reection Form

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Completed 10 November 2020

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