Georgia College & State University College of Health Sciences School of Nursing Preceptor Agreement Form Please fill in all blanks-- Please print or type all information Student Name: Student Telephone Number:

Semester: Course Name & Number: Number of Clinical Hours***:

***Please indicate the number of hours to be completed by the student at this location for the specified course and semester.

Preceptor Name: Preceptor License Number:

Preceptor Email Address (REQUIRED—please print legibly): Preceptor Cell Phone Number:

Number of years of practice in population focus area:

Agency/Practice Name: Agency/Practice Phone Number:

Agency/Practice Street Address : City, State, Zip:

Agency/Practice owned by (circle one): Name of Hospital/Corporation (if applicable): Independent/Private Practice or Hospital/Corporation Students have completed both a background check and urine drug screen after acceptance to the FNP program. This information is accessible through PreCheck. 1. This information is requested to be released to the above named clinical site: Yes_____ No_____ 2. Is additional screening is required by the agency? Yes_____ No_____ Person responsible for signing contracts: Email address for person responsible for signing contracts: Signature of person responsible for signing contracts:______Date:______

Signature of Preceptor:______Date:______Copy of current License attached ______YES ______NO Copy of Board Certification attached ______YES ______NO Signature of Student:______Date:______It is formally agreed that the student specified above will obtain clinical or administrative experience under the supervision of the above named preceptor at the agency specified above. The student is expected to participate in hours of clinical or administrative practice during the semester. The University will not provide remuneration for either the preceptor or the student . The student is expected to participate in a variety of clinical or administrative experiences as negotiated with the preceptor and approved by the supervising faculty member. The specific type of experience will be based upon the needs and structure of the agency as well as the curriculum provided in the nursing program. The supervising faculty member will assist the student in developing learning goals, identifying areas of strengths and weaknesses in the student’s practice, selecting appropriate learning experiences, and evaluating the student’s performance. The faculty member will work collaboratively with the student and preceptor to facilitate and evaluate learning experiences. Please return to Paige Alford by fax (478) 752-1077 or email ([email protected])

Signature of Supervising GCSU Faculty Member:______Date:______

Updated 9/29/14