Form A (BSN Programs) Policy C-04Clinical Site/Preceptor Assessment by FacultySemester*SpringSummerFallDate MM slash DD slash YYYY Faculty Member* First Last Faculty Email* Course Number* Name of Site* Site Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Clinical Unit* Type of Site*RuralUrbanType of Site*PublicPrivateNumber of Students at Site Unit*Characteristics of Clients at UnitGender*BothFemaleMaleUnderserved*YesNoAges* 0-18 19-64 65-100 All Clinical ExperiencesClinical Experiences Available* Preventive Episodic Chronic Acute Clinical Experiences are Adequate for Course Objectives*YesNoPreceptor Information at Site UnitName* First Last Email* Years of Practice in AreaPreviously Precepted StudentsYesNoAble to Provide Appropriate Learning Experiences*YesNoState License Number* State Licensure Expiration Date* MM slash DD slash YYYY National Certification Highest Nursing Degree*ADNBSNMSNPhDHighest Academic Degree*ADNBABSBSNMBAMDMSNPhDOtherAdditional Preceptors InformationIf no additional preceptors scroll down to Submit.Name First Last Email Years of Practice in AreaPreviously Precepted StudentsYesNoAble to Provide Appropriate Learning ExperiencesYesNoState License Number State Licensure Expiration Date MM slash DD slash YYYY National Certification Highest Nursing DegreeADNBSNMSNPhDHighest Academic DegreeADNBABSBSNMBAMDMSNPhDOtherName First Last Email Years of Practice in AreaPreviously Precepted StudentsYesNoAble to Provide Appropriate Learning ExperiencesYesNoState License Number State Licensure Expiration Date MM slash DD slash YYYY National Certification Highest Nursing DegreeADNBSNMSNPhDHighest Academic DegreeADNBABSBSNMBAMDMSNPhDOtherName First Last Email Years of Practice in AreaPreviously Precepted StudentsYesNoAble to Provide Appropriate Learning ExperiencesYesNoState License Number State Licensure Expiration Date MM slash DD slash YYYY National Certification Highest Academic DegreeADNBABSBSNMBAMDMSNPhDOtherHighest Nursing DegreeADNBSNMSNPhDName First Last Email Years of Practice in AreaPreviously Precepted StudentsYesNoAble to Provide Appropriate Learning ExperiencesYesNoState License Number State Licensure Expiration Date MM slash DD slash YYYY National Certification Highest Academic DegreeADNBABSBSNMBAMDMSNPhDOtherHighest Nursing DegreeADNBSNMSNPhD
