Preceptor Data Form

Preceptor Data Form

Preceptor Information

Are you a nursing professional or non-nursing professional?*

Nursing Professional

Non-Nursing Professional

Last Name*

First Name*

Credentials*

Title

If applicable

License Number(s)*

Please separate multiple license numbers with a comma

State(s) Licensed In*

Expiration Date(s)*

Board Certification Number*

Certifying Body*

Contact Information

Preferred Mailing Address*

City, State & Zip Code*

Primary Email*

Primary Phone Number*

Phone

Facility information

Facility Name*

Department/Unit

If applicable

Physical Address*

City, State & Zip Code*

Phone Number

Phone

Number of Beds/Exam Rooms*

Facility Type*

Please check all that apply

Rural clinic

Community health

Private practice

Non-profit

Urgent care

Inpatient

Primary care

Long term acute care

Pediatric primary care

OB/GYN

Newborn visits

Behavioral health

Family practice

Other

Other Facility Type*

Population(s) Served*

Please check all that apply

Newborns

Infants

Children

Adolescents

Adults

Women

Geriatrics

Educational Background and Experience

Degree(s)*

Please check all that apply

ADN

BA

BS

BSN

DNP

DNS

EdD

JD

MA

MBA

MD

MPH

MS

MSN

MSNEd

PharmD

PhD

Other

Other Degrees*

Are you a UNM CON alumni?*

Yes

No

Years of Nursing/Professional Experience*

Years with Current Facility*

How many years of experience do you have in your current position?*

Specialty Area(s)

If applicable

Are you CPR certified?*

Yes

No

Have you precepted before?*

Yes

No

Did you receive course and clinical objectives (written or verbal)?*

Yes

No

Did you receive orientation (written or verbal) for your role as a preceptor?*

Yes

No

What additional assistance would be beneficial to support and enhance your role as a preceptor?

Send me a copy of my responses

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