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

Educational Background and Experience

Are you a UNM CON alumni?

Yes

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

Have you precepted before?

Yes

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

Yes

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

Yes

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

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