APN/Graduate Preceptor Request
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APN/Graduate Nurse Preceptor Request
As a graduate student, please complete the information below to request a preceptor.
1.
First Name:
*
2.
Last Name:
*
3.
Phone Number:
(Format: (216) 444-4444)
*
4.
Email:
*
5.
School:
*
6.
Program:
*
7.
Program Director:
First Name:
*
8.
Last Name:
*
9.
Program Director Email:
*
10.
Program Director Phone Number:
(Format: (216) 444-4444)
*
11.
Clinical Rotation Needed:
*
Adult- Primary Care
Adult- Acute Care Adult
Education
Gerontology
Leadership/Management
Neonatal
Pediatrics-Primary
Pediatrics-Acute
Psychiatry
Women’s Health
Other, please specify
12.
Number of Hours:
*
13.
Timeframe:
*
Winter
Spring
Summer
Fall
14.
Objectives of the Course (from syllabus):
*
15.
Have you been a graduate student at any Cleveland Clinic hospital before?
*
Yes
No
16.
Have you contacted anyone at Cleveland Clinic as a preceptor?
*
No
Yes, please indicate who
17.
Are you a Cleveland Clinic employee?
*
Yes
No