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The Christ College of Nursing and Health Sciences

NUR 300

Preceptor Data Sheet

Course Description/Nursing 300

The Christ College of Nursing and Health Sciences

Preceptor Data Sheet

Part I: Nursing Practice Information

First Name :  
Middle Name :
Last Name :  
Phone # to best reach you :  
Email Address that is checked most frequently :  
In which state are you planning on precepting :

Current license number for the state in which you are precepting :  
Number of years experience as RN :  
Agency/Hospital Name:  
Unit:  
Manager Name:  
Unit Phone:  
Primary patient specialty admitted to your unit:  
(Examples: general surgical unit, ortho/neuro/surgical needs, medical-diabetic unit, etc.)
# of years worked with this patient population:  
# of hours direct patient care/week:  
Shift rotation worked (i.e.: 12h D; 12h N; evenings; weekend option 12h D; 8h D/N rotation:  

Part 2: Education Information

Name of nursing program(s) from which you graduated:  
Highest degree in Nursing:        
 
Current Specialty Nursing Certification (list):  
What does this mean?  
Please write a shot narrative indicating how you demonstrate experience in the area of clinical practice:
 
Have you worked as preceptor with a student nurse before?
Have you ever attended a preceptor workshop or training?
If necessary, are you willing to precept 2 students for this course?
 

By entering my name and email, I acknowledge that I have read and understand the rules and regulations with the appropriate state board of nursing as pertains to carrying out the duties of a preceptor.
Name of Preceptor :
(indicates Signature) 		  Date :  
Email Address :  
Questions or Concerns

Reviewed for compliance with OBN rule 4723-5-10- 1/2009 TL
Reviewed for compliance with KBN rule KRS 314.111 1/2009

The Christ College of Nursing and Health Sciences
2139 Auburn Avenue
Cincinnati, Ohio
Telephone: 513 585 2401
Fax: 513 585 3540
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