WOC Nursing Preceptor Application - Cleveland Clinic
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Please print a copy of this application for your records PRIOR to submitting. To contact us directly, please call (216) 444-5966 or email to WOCSchool@ccf.org
Please enter the following information:
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First & Last Name
WOC program graduated from
WOC certification exp. date
Please enter your contact information
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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 precepted a student from our program prior to this class? If so, please provide the student's name(s) and the date(s) precepted.
As part of your preceptor application process, please complete and remit the required "Preceptor Clinical Stats Form"; which describes your WOC practice and includes your patient population and average census. The Stats Form will pop up for your completion after you click the "submit" (done) button to this application below.
You may print, complete, and submit this form back to us within the next five business days.
Submit either via fax to 216-445-6343 or scan/email to
(NOTE: No preceptor application will be reviewed or approved without receipt of your clinical stats form.)
Three credentialing documents must accompany your preceptor application as follows: 1) copy of current CV or resume (which may be copied and pasted into this text box); 2) copy of WOCNCB ID card or certificate, and 3) Precepting Clinical Stats Form (in #9 above).
All documents may be submitted to us via fax to 216-445-6343 or scan/email to
(NOTE: No preceptor application will be reviewed or approved without receipt of these three required credentialing documents.)
Prior to the student's first day of didactic classes, a clinical affiliation agreement "template" must be received in our office. As all students are required to have a fully executed clinical affiliation agreement in place, between your facility and Cleveland Clinic, prior to the student starting his/her practicum with you. Cleveland Clinic does have a clinical affiliation agreement template available for review and use, if agreeable with your facility. It may be access as follows from our school's website:
Clinical Affiliation Agreement Template:
Click Here to Access Agreement Template
Clinical Affiliation Agreement Instruction Sheet:
Click Here to Access Agreement Instruction Sheet
Please submit these document onto the appropriate person, in your facility, who is responsible to negotiate and sign agreements asap. Ask that individual to return the appropriate clinical affiliation agreement "template" (our template or your facility's template (in an editable MS Word format)), before the student's first day of class, to us via either fax to 216-445-6343 or scan/email to
. Upon receipt, our school's paralegal will initate the review and approval process with your facility.
NOTE: Prior to the student starting clinicals at your site, a proposed clinical schedule (evidencing the number of clinical hours per day) must be submitted to the school. Fax to 216-445-6343 or scan/email to WOCschool@ccf.org.