Preceptor Sign-Up Form

Preceptor Sign-Up Form

First Name*

Last Name*

Title*

Office Number*

Email*

Department*

Department Location*

Department Secondary Contact

Please list a secondary contact for the department that will be in direct contact with the student intern.

Secondary Contact Name*

Secondary Contact Title*

Secondary Contact Email*

Secondary Contact Number*

Is your department clinical or non-clinical?*

Select

How many interns can the department support?*

What session(s) are you able to host interns? (select all that apply)*

Select

Preferred times of the day to host interns?*

(Select all that apply)

Select

Preferred Skills/Training for interns?

(i.e., Entry Level, EPIC, ECG Tech Cert., Communication)

LeapOnline Modules Specific to Unit/Department?

(i.e., Fall/Slip, Safe & Secure, Medical Terminology)

Please list any specific restrictions or age requirements for your department.

List Duties/Responsibilities interns may have.*

Can you share other learning opportunities interns may experience in your departments?*

(e.g., surgeries/procedures, workshops, team meetings, etc.)

Any questions or follow up comments.

Send me a copy of my responses