Full Name
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Credentials
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Name of Current Facility
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Facility Physical Address
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Facility Phone Number
Phone
Contact Information
Contact Information
Email
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Phone Number
Phone
Years of Nursing Experience
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Years with Current Organization
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Type(s) of Practice
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Please check all that apply.
Primary Care
Inpatient
Urgent Care
Long Term Acute Care
Private Practice
Rural Clinic
Speciality
Population(s) Served
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Newborns
Infants
Children
Adolescents
Adults
Women & Birthing People
Geriatrics
Have you precepted BSN or APRN students?
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BSN
APRN
I have never precepted before.
What students are you interested in taking?
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BSN
APRN
How did you hear about us?
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