Preceptor Application
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Please print a copy of this application for your records PRIOR to submitting.
1.
Please enter the following information:
*
Enter Information Here
Name
Degree(s)
WOC program graduated from
WOC certification exp. date
2.
Please enter your contact information
*
Enter information here:
Name of business
Address
City
State
Zip code
Business Phone
Pager
Mobile Phone
FAX
Email address
employed full or part-time?
3.
What is the name of the student you will be precepting?
*
4.
Would you like to be included in our preceptor data base to precept future students?
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Yes
No
5.
Please describe the facility you are working in (e.g. acute care/home care/ambulatory)
*
6.
Please describe your previous teaching experience.
*
7.
Please describe any previous precepting experience you have.
*
8.
Have you ever attended a preceptor workshop?
*
Yes
No
9.
Have you precepted a student from our program prior to this class? If so, please provide the student name and the date(s) precepted:
10.
Please describe your WOC practice including patient population and average census
*
11.
Please enter the proposed clinical calendar for this student
*
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12.
Please copy/paste your CV or resume into this text box
*
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13.
A clinical contract between your agency and the Cleveland Clinic must be completed prior to the student beginning class. The student has a template of a contract designed specifically for our WOC nursing education program. If you have any specific questions, please enter here. Please print a copy of this application for your records PRIOR to submitting.