NUR 4106 Clinical Preceptor Agreement and Info

Clinical Preceptor's Name Clinical Preceptor's Name First Last
RN License Number
State that issued RN license
Current Title/Position
Time in current position

Must have 2 years in current management position.
Previous experience to be considered if less that 5 years in current position. Mark n/a if the question does not apply.
Last completed nursing degree

Last completed nursing degree BSN MSN DNP PhD
Student's Name Student's Name First Last
I agree to function in the preceptor role to facilitate (student) in achieving course outcomes and the required 90 clinical hours. I will provide opportunities for this student to observe me in my role, provide direct supervision of the student during performance of any procedures as needed, provide feeback to the student regarding clinical performance, and complete the evaluation tools as outlined by the clinical packet.

Any falsification of this document by students will result in referral to the Office of Student Standards.
Date Date / MM / DD YYYY
Note: A clinical preceptor or manager of the clinical agency may discontinue the clinical arrangement with a student at any time through communication with the class instructor.
Clinical Address Clinical Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Primary Email
Secondary Email
Primary Phone Primary Phone - ### - ### ####
Print a copy prior to submission