Emory University

WOCNEC


Application

for

Alternate Clinical Provider

(Continence Only)


We are delighted you are interested in serving as an off-site Alternate Clinical Provider for the Emory University Wound, Ostomy, and Continence Nursing Education Center (WOCNEC).


The information requested below is required to meet accreditation standards. You will note all the eligibility requirements are listed first to avoid wasted efforts if you are not currently eligible.


If you have any questions, please contact us at: wocnec@emory.edu or If you have any questions, please contact us at: wocnec@emory.edu or 404-778-4067.

 
 
mm/dd/yyyy
 
 
 

Eligibility Requirements

 

Must specialize in urology and/or continence and be clinically competent to provide preceptorship for continence students.


I attest that I meet the Clinical Experience requirement.

 

No minimum requirement.

 

No minimum requirement.

 
 
 
 
mm/dd/yyyy
 

Certification not required.

 
 
 

Contact Information

 
 
 
 
 
 
 
 
 
 
 
Phone
 
 

Optional

Phone
 
 

Optional

 
 
 

Clinical Practice

 
 
 

Only include the setting(s) you will be precepting in.

 

If precepting in multiple settings, choose the range that corresponds with the setting you will spend the most time precepting in.

 

Maximum 1:2

 

%'s must equal 100%

 
 
 
 

Is there a specific student you are applying to precept for?

 
 
 

Thank you!