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Please print a copy of this application for your records PRIOR to submitting.
Please enter the following information:
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WOC program graduated from
WOC certification exp. date
Please enter your contact information
Enter information here:
Name of business
employed full or part-time?
What is the name of the student you will be precepting?
Would you like to be included in our preceptor data base to precept future students?
Please describe the facility you are working in (e.g. acute care/home care/ambulatory)
Please describe your previous teaching experience.
Please describe any previous precepting experience you have.
Have you ever attended a preceptor workshop?
Have you precepted a student from our program prior to this class? If so, please provide the student name and the date(s) precepted:
Please describe your WOC practice including patient population and average census
Please enter the proposed clinical calendar for this student
Please copy/paste your CV or resume into this text box
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.