School of Nursing Graduate Program Preceptor Forms

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School of Nursing Graduate Program Preceptor Forms

• Preceptor
• Agreement Forms
• and Addendums

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Preceptor Forms Office Routing Process

• Choosing your Preceptor - if uncertain about
  choices of preceptors, the Preceptor Directory
  (also accessible on the student web page), has
  preceptors used by students within the last 2
  years. You may also choose one of your own.
  Remember, this is just a guide to help find a
  preceptor, you will still have to fill out the
  form.
• Submitting forms - fax, email or mail preceptor
  forms to Katherine Fitch, Graduate Program
  Office. If faxed or emailed, the original form
  must be mailed. Students should always keep a
  copy of the original for their records.
• Verification - the students immunizations,
  license, preceptors certification and expiration
  dates will be verified at this time. If a
  student needs to be contacted about their
  immunizations it will be done via email, so
  remember to check your ttuhsc.edu email daily.
• Approval the form will be forwarded to clinical
  faculty for approval. Clinical Faculty will
  notify the student of the approval and they can
  begin his/her clinicals at that time.
• Elogs the student and preceptor will be added
  into elogs after the form has been approved by
  the Clinical Faculty. An acknowledgement letter
  will also be sent at this time to let the
  preceptor know the Facultys contact information.
• Final approvals the forms will then be sent to
  the Course Facilitator and Department Chairs for
  signatures.
• Contact Information
• Katherine Fitch
• 3601 4th St., Stop 6264
• Lubbock, TX 79430-6264
• Office [phone] Fax [phone]
• Katherine.fitch_at_ttuhsc.edu

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Preceptor Agreement Form

• A form or addendum must be submitted each
  semester a student will be working with a
  preceptor.
• The preceptors must fill out the shaded/yellow
  areas, items 17-25 and item 31
• Students must keep a copy of the preceptor form
  for use in filling an addendum out the following
  semesters
• For information on filling out your addendum,
  click here.

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Click on each arrow for information on filling
out that line.
Remember shaded/yellow areas are to be filled in
by the preceptor.
For information on filling out the addendum,
click here.
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Step by Step for Student

• Student name (only one student can be listed per
  sheet)
• Student track (ex FNP, ACNP, PNP, GNP, Ed,
  Admin)
• Current semester and year
• You must fill out a new preceptor form or an
  addendum every semester!

Back to form
6
Step by Step for Student, Cont.

• Course number (only one course per preceptor
  form)
• Location- site (ex Lubbock, Permian Basin, El
  Paso, Highland Lakes, Fred/Kerr)
• Clinical faculty name
• You must know your facultys name for the form to
  processed.

Back to form
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Step by Step for Student, Cont.

• Course facilitator name
• Preceptors name and credentials
• Date the form is filled out
• Position and title of your preceptor
• Facility name (the name of the facility where you
  will be doing your clinical hours)
• Please do not abbreviate

Back to form
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Step by Step for Student, Cont.

• Mailing address (of the facility where you will
  be doing your clinical hours with the preceptor).
• Please include the complete address with the zip
  code.
• City, State, Zip
• County, the county clinic is located in.
• Note county, not country

Back to form
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Step by Step for Student, Cont.

• Preceptors email address
• Telephone number(s) for the preceptor

Back to form
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Step by Step for Preceptor

• Preceptors social security number (OPTIONAL)
• Preceptors professional license number, not
  their drivers license number
• State of preceptors license
• Date of expiration of license
• Certification type

Back to form
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Step by Step for Preceptor, Cont.

• Date of expiration of certification- month/year
• Certifying board name (ex AANP, ANCC, PCNB,
  ABFP, AAFP, etc.)

Back to form
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Step by Step for Preceptor, Cont.

• Educational background information (please
  include Degree and Date of Completion for both
  College/University and Graduate/Professional
  sections)
• This must be completed to process the form.
• Please do not send CVs the dates of completion
  are all that is needed.

Back to form
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Step by Step for Preceptor, Cont.

• Check appropriate box indicating the
  classification of facility (check one)
• Obtain from Administrator at site

Back to form
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Step by Step for Student

• Preceptors name
• Students name
• Course number

Back to form
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Step by Step for Student, Cont.

• Month and year (or semester and year) when
  preceptor will begin clinical hours with student.
• This form will be valid for up to one year so
  only an addendum will need to be submitted the
  next semester.
• Month and year (or semester and year) when
  preceptor will end clinical hours with student,
  up to one year.

Back to form
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Step by Step for Preceptor, Cont.

• Preceptors signature and date

Back to form
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Preceptor Addendums

• In order to fill out the addendum, you will need
  to refer to your original copy of the preceptor
  form from the previous semester.
• The addendum is a continuation form. If you are
  using the same preceptor from a previous
  semester, then you only need to turn in an
  addendum.
• Students are responsible for filling out the
  entire addendum
• Only the student signature is required.

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Click here to skip to links.
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Step by Step for Student

• Clinical faculty name
• Clinical facilitator name
• Semester and year (only good for one semester)
• Enter your location (ex Lubbock, Permian Basin,
  Fred/Kerr, etc.)
• Enter your track (ex FNP, ACNP, PNP, GNP, Ed,
  Admin)

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Step by Step for Student, Cont.

• Student name (only one student per form)
• Preceptors name and credentials
• Semester and year (repeat of 3)
• Circle only one (one course per addendum)
• Preceptors professional license number, not the
  drivers license number.
• The expirations date of the preceptors license

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Step by Step for Student, Cont.

• The expiration date of preceptor agreement (can
  be found at the bottom of the original preceptor
  form)
• Student signature and date

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Online Links to All Forms

• Preceptor Agreement Form
• http//nursing.ttuhsc.edu/forms/pdfs/Preceptor_Agr
  eement.pdf
• Addendum Form
• http//nursing.ttuhsc.edu/forms/pdfs/Addendum_Form
  s.pdf