Preceptor or Clinical Mentor Information Form - Copy

Intro.Txt PRECEPTOR/CLINICAL MENTOR INFORMATION AND CONTRACT FORM

Intro.1 Thank you very much for agreeing to precept or mentor a University of Toledo College of Nursing student. If this is your first time completing the on-line version of the contract information form, you must complete all sections before submitting the form. The Preceptor/Clinical Mentor Information and Contract Form can ONLY be completed and submitted on-line. We will not accept copied, handwritten, or previous versions of this document. If you have completed the on-line version of this form previously, please carefully review SECTIONS I – IX for accuracy and make any necessary changes, then fully then complete SECTION X. We recommend the first time you complete this form that you do not use a small mobile device, such as a cell phone, since some sections may not fit the viewing screen. Please ensure you are using the Internet browser Mozilla Firefox to complete this survey.

Q1.1 SECTION I OHIO ADMINISTRATIVE CODE (OAC) RULES Please read these rules and click on the statement below the rules indicating that you have read them. Rule 4723-5- 10(A)(5), OAC, specifies that a Preceptor for an RN nursing education program shall have (a) completed an approved registered nursing education program; (b) have experience for at least two years in the practice of nursing as an RN with demonstrated competence in the area of clinical practice in which the Preceptor provides supervision to a nursing student; (c) have a current, valid license as an RN. A BSN is preferred. Rule 4723-5-20(F), OAC, specifies that the teaching assistant or Preceptor providing supervision of a nursing student shall at least: (1) Have competence in the area of clinical practice in which the teaching assistance or Preceptor is providing supervision to a student; (2) Design, at the direction of a faculty member, the student’s experience to achieve the stated objectives or outcomes of the nursing course in which the student is enrolled; (3) Clarify with the faculty member; (a) The role of the teaching assistant or Preceptor; (b) The responsibilities of the faculty member; (c) The course and clinical objectives or outcomes; (d) The clinical experience evaluation tool; and (4) Contribute to the evaluation of the student’s performance by providing information to the faculty member and the student regarding the student’s achievement of established objectives or outcomes. Rule 4723-5-20(G), OAC, specifies that a Preceptor shall provide supervision to no more than two nursing students at any one time, provided the circumstances are such that the Preceptor can adequately supervise the practice of both students.  I have read the above Ohio Administrative Code (OAC) Rules (1)

Q2.Txt SECTION II DEMOGRAPHIC INFORMATION

Q2.1 2.1. Please check over the following information about yourself. Please correct anything that is incorrect and fill in any blanks. Suffix: Mr, Mrs, Ms, or Dr. (1) First Name (2) Last Name (3) Home Address (4) City (5) State (Two letter abbreviation) (6) Zip Code (7) Home Phone Number (XXX-XXX-XXXX) (8) Cell Phone Number (XXX-XXX-XXXX) (9) Personal E-mail Address (Home) (10)

Q3.Txt SECTION III EDUCATION INFORMATION

Q3.1 3.1. Please select which of the following degree(s) you were awarded from the list below. Please include any programs in which you are currently enrolled. Please select ALL THAT APPLY.  LPN (Licensed Practical Nurse) (1)  Diploma Nurse (2)  ADN (Associate Degree Nurse) (3)  BSN (Baccalaureate Nurse) (4)  MSN (Master Nurse) (5)  CNL (Clinical Nurse Leader) (6)  APN (Advanced Practice Nurse) (7)  CNS (Clinical Nurse Specialist) (8)  DNP (Doctorate of Nursing Practice) (9)  MD (Medical Doctor) (10)  DO (Doctor of Osteopathy) (11)  PhD (12)  Other Degree 1 (13)  Other Degree 2 (14)

Answer If 3.1. Please select which of the following degree(s) you were awarded from the list below. Please include any programs in which you are currently enrolled. Please select ALL THAT APPLY. PhD Is Selected Or 3.1. Please select which of the following degree(s) you were awarded from the list below. Please include any programs in which you are currently enrolled. Please select ALL THAT APPLY. Other Degree 1 Is Selected Or 3.1. Please select which of the following degree(s) you were awarded from the list below. Please include any programs in which you are currently enrolled. Please select ALL THAT APPLY. Other Degree 2 Is Selected Q3.1a 3.1a. Please provide additional detail about the degrees you selected in the prior question. If 3.1. Please select which of the following degree(s) you were awarded from the list below. Please include any programs in which you are currently enrolled. Please select ALL THAT APPLY. PhD Is Selected  PhD (Please Define) (1) ______If 3.1. Please select which of the following degree(s) you were awarded from the list below. Please include any programs in which you are currently enrolled. Please select ALL THAT APPLY. Other Degree 1 Is Selected  Other Degree 1 (Please Define) (2) ______If 3.1. Please select which of the following degree(s) you were awarded from the list below. Please include any programs in which you are currently enrolled. Please select ALL THAT APPLY. Other Degree 2 Is Selected  Other Degree 2 (Please Define) (3) ______

Q3.2 3.2. Please list the school/college/university, the month and year of graduation, and the years in clinical practice (if applicable) for the degrees you selected above. If you are currently in a program of study, please select your expected month and year of graduation. Please scroll to the right ⇒ if you do not see all 4 columns on your screen viewer.

Q4.Txt SECTION IV LICENSE INFORMATION The University of Toledo College of Nursing is required to maintain current documentation of license information and verifies the license of each Preceptor or Clinical Mentor.

Q4.1 4.1. License Information Please provide the following required information about your current license. License Number (1) State License was Issued (two letter abbreviation) (2) Expiration Date (mm/dd/yyyy) (3)

Q4.2 4.2. Do you hold an out of state license?  Yes (1)  No (2)

Answer If 1a) Do you hold an out of state license? Yes Is Selected Q4.2a 4.2a. Out of State License Information Please provide the following information about your out of state license. License Number (1) State License was Issued (two letter abbreviation) (2) Expiration Date (mm/dd/yyyy) (3)

Q5.Txt SECTION V CERTIFICATION INFORMATION

Q5.1 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by holding down the "Control" key and selecting multiple specialties.  Advanced Life Support (1)  Adult/Family Health Nursing (2)  Advice/Call Nursing (3)  Case Management Nursing (4)  Community Health Nursing (5)  Critical Care/Cardiovascular Nursing (6)  Dermatology Nursing (7)  Diabetes Education (8)  Emergency Nursing (9)  Forensic Nursing (10)  Gastroenterology Nursing (11)  Gerontology Nursing (12)  Home Health Nursing (13)  Hospice Nursing (14)  Infusion Nursing (15)  Informatics Nursing (16)  Intermediate Care Nursing (17)  Lactation Nursing (18)  Leadership/Management (19)  Legal Nursing (20)  Medical-Surgical Nursing (21)  Nephrology Nursing (22)  Neuroscience Nursing (23)  Oncology Nursing (24)  Orthopedic Nursing (25)  Pediatric Nursing (26)  Peri-Operative Nursing (27)  Professional Development (28)  Psychiatric and Mental Health Nursing (29)  Public Health (30)  Radiological Nursing (31)  Rehabilitation Nursing (32)  School Nursing (33)  Urologic Nursing (34)  Women's Health Nursing (35)  Wound, Ostomy, Continence Nursing (36)  Other (37)

Answer If What is your current area of specialty practice?  Please select all that apply by holding down the Control key and selecting multiple specialties. Other Is Selected Q5.1a 5.1a. Please provide more detail about the "Other" specialty you selected in the prior question.

Q5.2 5.2. Do you hold any nursing certifications in your current area(s) of specialty practice?  Yes (1)  No (2) If No Is Selected, Then Skip To End of Block

Q5.3 5.3. Please select which of the following certifications you hold in each of your areas of specialty.

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by  Advanced  Pediatric holding down the Cardiac Life Advanced Life "Control" key and  None (3)  (4)  (5)  (6)  (7) Support Support (PALS) selecting multiple (ACLS) (1) (2) specialties. Advanced Life Support Is Selected Advanced Life Support (x1) If 5.1. What is your current area of specialty practice? Please select  Acute ALL THAT APPLY by Care  Adult  Family Nurse holding down the  Adult Nurse Nurse Health CNS  Adult Nurse Practitioner  Family Nurse "Control" key and Practitioner Board Practitione Board  None Practitioner Board Practitioner selecting multiple Certified (APN- r Board Certified (7) (APN) (1) Certified (FNP) (4) specialties. Adult/Family BC) (2) Certified (ACSN-BC) (FNP-BC) (3) Health Nursing Is (ACNP- (6) Selected BC) (5) Adult/Family Health Nursing (x2) If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by  Ambulatory holding down the Care Nurse  None (2)  (3)  (4)  (5)  (6)  (7) "Control" key and (ACN) (1) selecting multiple specialties. Advice/Call Nursing Is Selected Advice/Call Nursing (x3) If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by holding down the  Nursing Case "Control" key and Management  None (2)  (3)  (4)  (5)  (6)  (7) selecting multiple (NCM) (1) specialties. Case Management Nursing Is Selected Case Management Nursing (x4) If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by holding down the  Community  Faith  Home Health "Control" key and Health  Home Health Community CNS  None (5)  (6)  (7) selecting multiple Nursing Nursing (HHN) (2) Nursing (AFCN) (HHCNS) (3) specialties. Community (CHN) (1) (4) Health Nursing Is Selected Community Health Nursing (x5) If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by  Cardiac holding down the Medicine  Progressive  Certified  Cardiac  Cardiac Surgery "Control" key and Sub- Care Critical Care  Critical Care CNS Vascular Sub-specialty  None selecting multiple specialty Nursing Nurse (CCNS) (2) Nurse (CVN) Certification (7) specialties. Critical Certificatio Certification (CCRN) (1) (3) (CSC) (4) Care/Cardiovascular n (CMC) (PCCN) (6) Nursing Is Selected (5) Critical Care/Cardiovascular Nursing (x6) If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by  Dermatology holding down the Nurse "Control" key and  None (2)  (3)  (4)  (5)  (6)  (7) Certified selecting multiple (DNC) (1) specialties. Dermatology Nursing Is Selected Dermatology Nursing (x7) If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by  Certified  Diabetes  Diabetes holding down the Diabetes Management Management  None (4)  (5)  (6)  (7) "Control" key and Educator Advanced Nurse (DMN) (2) selecting multiple (CDE) (1) (DMA) (3) specialties. Diabetes Education Is Selected Diabetes Education (x8) If 5.1. What is your  Certified  Certified Flight  Emergency current area of specialty Emergency Registered Nurse Nurse  None (4)  (5)  (6)  (7) practice? Please select Nurse (CEN) (CFRN) (2) Practitioner ALL THAT APPLY by (1) (ENP) (3) holding down the "Control" key and selecting multiple specialties. Emergency Nursing Is Selected Emergency Nursing (x9) If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by  Certified holding down the Forensic  SANE-A (2)  SANE-P (3)  SANE-P/A (4)  None (5)  (6)  (7) "Control" key and Nursing (CFN) selecting multiple (1) specialties. Forensic Nursing Is Selected Forensic Nursing (x10) If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by holding down the  Certified "Control" key and Gastroenterol  None (2)  (3)  (4)  (5)  (6)  (7) selecting multiple ogy Nurse specialties. (CGRN) (1) Gastroenterology Nursing Is Selected Gastroenterology Nursing (x11) If 5.1. What is your current area of specialty practice? Please select  Gerontological ALL THAT APPLY by  Gerontological  Adult- Nurse  Gerontological holding down the Nurse Gerontology Practitioner CNS Board "Control" key and  None (5)  (6)  (7) Certified Primary Care NP Board Certified selecting multiple (GNC) (1) (AGNP) (2) Certified (GCNS) (4) specialties. Gerontology (GNP) (3) Nursing Is Selected Gerontology Nursing (x12) If 5.1. What is your current area of specialty practice? Please select  Home Health ALL THAT APPLY by Nurse holding down the  None (2)  (3)  (4)  (5)  (6)  (7) Certification "Control" key and (HHNC) (1) selecting multiple specialties. Home Health Nursing Is Selected Home Health Nursing (x13) If 5.1. What is your current area of specialty practice? Please select  Advanced ALL THAT APPLY by  Certified  Pain Certified Hospice holding down the Hospice and Management and Palliative  None (4)  (5)  (6)  (7) "Control" key and Palliative Nurse (RN- Nurse (ACHPN) selecting multiple (CHPN) (1) BC) (3) (2) specialties. Hospice Nursing Is Selected Hospice Nursing (x14) If 5.1. What is your current area of specialty practice? Please select  Vascular ALL THAT APPLY by  Certified Access- holding down the Registered Nurse Board  None (3)  (4)  (5)  (6)  (7) "Control" key and Infusion (CRNI) Certified (VA- selecting multiple (2) BC) (1) specialties. Infusion Nursing Is Selected Infusion Nursing (x15) If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by holding down the  Informatics "Control" key and Nursing (RN-  None (2)  (3)  (4)  (5)  (6)  (7) selecting multiple BC) (1) specialties. Informatics Nursing Is Selected Informatics Nursing (x16) If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by holding down the  Progressive "Control" key and Care Certified  None (2)  (3)  (4)  (5)  (6)  (7) selecting multiple Nurse (PCCN) specialties. Intermediate (1) Care Nursing Is Selected Intermediate Care Nursing (x17) If 5.1. What is your  Certified current area of specialty Lactation  None (2)  (3)  (4)  (5)  (6)  (7) practice? Please select Consultant ALL THAT APPLY by (IBCLC) (1) holding down the "Control" key and selecting multiple specialties. Lactation Nursing Is Selected Lactation Nursing (x18) If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by  Nurse  Certified holding down the Executive Nurse  Nurse Executive "Control" key and Advanced Manager and Board Certified  None (4)  (5)  (6)  (7) selecting multiple Board Leader (NE-BC) (2) specialties. Certified (CNML) (1) Leadership/Management (NEA) (3) Is Selected Leadership/Management (x19) If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by  Legal Nurse holding down the Consultant  None (2)  (3)  (4)  (5)  (6)  (7) "Control" key and Certification selecting multiple (LNCC) (1) specialties. Legal Nursing Is Selected Legal Nursing (x20) If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by  Certified holding down the Medical "Control" key and Surgical  None (2)  (3)  (4)  (5)  (6)  (7) selecting multiple Registered specialties. Medical- Nurse Surgical Nursing Is (CMSRN) (1) Selected Medical-Surgical Nursing (x21) If 5.1. What is your current area of specialty practice? Please select  Certified  Certified  Certified ALL THAT APPLY by Hemodialysis Peritoneal Nephrology holding down the  None (4)  (5)  (6)  (7) Nurse (CHN) Dialysis Nurse Nurse (CNN) "Control" key and (1) (CPN) (2) (3) selecting multiple specialties. Nephrology Nursing Is Selected Nephrology Nursing (x22) If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by  Certified holding down the Neuroscience "Control" key and Registered  None (2)  (3)  (4)  (5)  (6)  (7) selecting multiple Nurse specialties. (CNRN) (1) Neuroscience Nursing Is Selected Neuroscience Nursing (x23) If 5.1. What is your current area of specialty practice? Please select  Advanced  Advanced ALL THAT APPLY by  Oncology  Certified  Certified Pediatric Oncology Oncology holding down the Certified Breast Care Oncology (CPON) Certified Nurse CNS  None (6)  (7) "Control" key and Nurse (OCN) Nurse (CBCN) (2) Practitioner (AOCNS) selecting multiple (1) (3) (AOCNP) (4) (5) specialties. Oncology Nursing Is Selected Oncology Nursing (x24) If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by  Orthopedic holding down the  Orthopaedic  Orthopaedic Nurse "Control" key and Nurse Practitioner CNS (OCNS)  None (4)  (5)  (6)  (7) Certified selecting multiple (ONP) (2) (3) (ONC) (1) specialties. Orthopedic Nursing Is Selected Orthopedic Nursing (x25) If 5.1. What is your current area of specialty practice? Please select  Certified ALL THAT APPLY by Neonatal  Pediatric holding down the  Pediatric Nursing  Pediatric CNS Intensive Care Primary Care  None (5)  (6)  (7) "Control" key and (PN) (2) (PCNS) (3) Nurse (RNC- NP (PNP) (4) selecting multiple NIC) (1) specialties. Pediatric Nursing Is Selected Pediatric Nursing (x26) If 5.1. What is your  Certified  Certified Post  Certified  Certified Nursing  Certified RN current area of specialty Registered Anesthesia Ambulator Operating Room First Assistant  None (6)  (7) practice? Please select Nurse Registered y (CNOR) (2) (CRNFA) (4) ALL THAT APPLY by Anesthetist Nurse (CPAN) Perianesth holding down the (CRNA) (1) (3) esia Nurse "Control" key and (CAPA) (5) selecting multiple specialties. Peri- Operative Nursing Is Selected Peri-Operative Nursing (x27) If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by holding down the  Nursing "Control" key and Professional  None (2)  (3)  (4)  (5)  (6)  (7) selecting multiple Development specialties. Professional (NPD) (1) Development Is Selected Professional Development (x28) If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by  Adult Psychiatric  Adult  Child/Adolescent holding down the  Psychiatric and Mental Psychiatric– Psychiatric– "Control" key and Mental Health Health Nurse Mental Health Mental Health  None (5)  (6)  (7) selecting multiple Nurse Practitioner Board CNS CNS (PMHCNS- specialties. Psychiatric (PMHN) (1) Certified (PMHCNS- BC) (4) and Mental Health (PMHNP) (2) BC) (3) Nursing Is Selected Psychiatric and Mental Health Nursing (x29) If 5.1. What is your current area of specialty practice? Please select  Advanced ALL THAT APPLY by  Public Health  Public/Community Public Health holding down the Nursing Health CNS Nursing Board  None (4)  (5)  (6)  (7) "Control" key and (PHN) (1) (PHCNS) (2) Certified selecting multiple (APHN) (3) specialties. Public Health Is Selected Public Health (x30) If 5.1. What is your current area of specialty  Certified practice? Please select Radiological ALL THAT APPLY by  None (2)  (3)  (4)  (5)  (6)  (7) Nurse (CRN) holding down the (1) "Control" key and selecting multiple specialties. Radiological Nursing Is Selected Radiological Nursing (x31) If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by  Certified holding down the Rehabilitation  Cardiac "Control" key and Registered Rehabilitation  None (3)  (4)  (5)  (6)  (7) selecting multiple Nurse Nursing (CRN) (2) specialties. (CRRN) (1) Rehabilitation Nursing Is Selected Rehabilitation Nursing (x32) If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by  National  School Nurse holding down the Certified Practitioner (SNP)  None (3)  (4)  (5)  (6)  (7) "Control" key and School Nurse (2) selecting multiple (NCSN) (1) specialties. School Nursing Is Selected School Nursing (x33) If 5.1. What is your current area of specialty practice? Please select  Certified ALL THAT APPLY by Urologic holding down the Certified  None (2)  (3)  (4)  (5)  (6)  (7) "Control" key and Nurse selecting multiple (CURN) (1) specialties. Urologic Nursing Is Selected Urologic Nursing (x34) If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by  Certified holding down the  Maternal  Certified Inpatient  High-Risk  Inpatient "Control" key and Newborn Nurse Obstetrics Perinatal Nursing Obstetric Nurse  None (6)  (7) selecting multiple Nurse (RNC- Midwife Nurse (RNC- (2) (RNC-OB) (4) specialties. Women's MNN) (3) (CNM) (5) OB) (1) Health Nursing Is Selected Women's Health Nursing (x35) If 5.1. What is your  Certified  Certified Wound  Certified  Certified Ostomy  Certified  None (6)  (7) current area of specialty Wound, Ostomy Nurse Wound Care Care Nurse Continenc practice? Please select Ostomy, (CWON) (2) Nurse (COCN) (4) e Care ALL THAT APPLY by Continence (CWCN) (3) Nursing holding down the Nurse (CCCN) "Control" key and (CWOCN) (1) (5) selecting multiple specialties. Wound, Ostomy, Continence Nursing Is Selected Wound, Ostomy, Continence Nursing (x36) If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by holding down the  Other (1)  (2)  (3)  (4)  (5)  (6)  (7) "Control" key and selecting multiple specialties. Other Is Selected Other (x37)

Answer If 5.3. Please select which of the following certifications you hold in each of your areas of specialty. Other - Other Is Selected Q5.3a 5.3a. Please provide more detail about the "Other" certification you selected in the prior question.

Q5.4 5.4. Please select the month and year of your renewal date and the granting certification organization for the certification(s) selected in the previous question. 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(24 n n n ses on (9) ) g (16 min ve ses ) (25 (5) Bo olo (20 An (23 ) Bo Bo Pro (4) (6) (11 ) ers Nur (19 ) ard gy ) est ) ard ard gra ) (17 ses ) (8) (12 heti (26 (2) m ) (18 ) sts ) (3) ) (21 ) Adva nced Cardi ac Life                                                              Supp ort (ACL S) (1) Pedia tric Adva nced Life                                                              Supp ort (PAL S) (9) Adult Nurs                                                              e Practi tioner (APN ) (10) Adult Nurs e Practi tioner Boar                                                              d Certif ied (APN -BC) (11) Famil y Nurs e Practi tioner Boar                                                              d Certif ied (FNP -BC) (12) Famil y Nurs e                                                              Practi tioner (FNP ) (13) Acute Care Nurs e Practi tioner Boar                                                              d Certif ied (ACN P- BC) (14) Adult Healt h CNS Boar d                                                              Certif ied (ACS N- BC) (15) Amb ulator y Care                                                              Nurs e (ACN ) (19) Nursi ng Case Mana geme                                                              nt (NC M) (20) Com munit y Healt h                                                              Nursi ng (CHN ) (21) Hom e Healt h                                                              Nursi ng (HHN ) (22) Hom                                                              e Healt h CNS (HHC NS) (23) Faith Com munit y Nursi                                                              ng (AFC N) (32) Certif ied Critic al Care                                                              Nurs e (CCR N) (33) Critic al Care CNS                                                              (CCN S) (34) Cardi ac Vasc ular                                                              Nurs e (CVN ) (35) Cardi ac Surg ery                                                              Sub- speci alty Certif icatio n (CSC ) (36) Cardi ac Medi cine Sub- speci alty                                                              Certif icatio n (CM C) (37) Progr essiv e Care Nursi ng                                                              Certif icatio n (PCC N) (38) Derm atolo gy Nurs e                                                              Certif ied (DNC ) (39) Certif ied Diab etes                                                              Educ ator (CDE ) (40) Diab etes                                                              Mana geme nt Nurs e (DM N) (41) Diab etes Mana geme nt                                                              Adva nced (DMA ) (42) Certif ied Emer genc y                                                              Nurs e (CEN ) (43) Certif ied Flight Regis tered                                                              Nurs e (CFR N) (44) Emer genc y Nurs e                                                              Practi tioner (ENP ) (45) Certif ied Fore                                                              nsic Nursi ng (CFN ) (46) SAN E-A                                                              (47) SAN E-P                                                              (48) SAN E-                                                              P/A (49) Certif ied Gastr oente rolog y                                                              Nurs e (CGR N) (50) Gero ntolo gical Nurs e                                                              Certif ied (GNC ) (51) Adult - Gero ntolo gy Prim                                                              ary Care NP (AGN P) (52) Gero ntolo                                                              gical Nurs e Practi tioner Boar d Certif ied (GNP ) (53) Gero ntolo gical CNS Boar d                                                              Certif ied (GCN S) (54) Hom e Healt h Nurs e                                                              Certif icatio n (HHN C) (55) Certif ied Hospi ce and                                                              Pallia tive (CHP N) (56) Adva nced Certif                                                              ied Hospi ce and Pallia tive Nurs e (ACH PN) (57) Pain Mana geme nt Nurs                                                              e (RN- BC) (58) Vasc ular Acce ss- Boar d                                                              Certif ied (VA- BC) (59) Certif ied Regis tered Nurs e                                                              Infusi on (CRN I) (60) Infor matic s Nursi                                                              ng (RN- BC) (61) Progr                                                              essiv e Care Certif ied Nurs e (PCC N) (62) Certif ied Lacta tion Cons                                                              ultant (IBCL C) (63) Certif ied Nurs e Mana ger                                                              and Lead er (CN ML) (64) Nurs e Exec utive Boar d                                                              Certif ied (NE- BC) (65) Nurs e Exec utive                                                              Adva nced Boar d Certif ied (NEA ) (66) Legal Nurs e Cons ultant Certif                                                              icatio n (LNC C) (67) Certif ied Medi cal Surgi cal Regis                                                              tered Nurs e (CMS RN) (68) Certif ied Hem odial ysis                                                              Nurs e (CHN ) (69) Certif ied Perit oneal Dialy                                                              sis Nurs e (CPN ) (70) Certif                                                              ied Neph rolog y Nurs e (CNN ) (71) Certif ied Neur oscie nce Regis                                                              tered Nurs e (CNR N) (72) Onco logy Certif ied                                                              Nurs e (OCN ) (73) Certif ied Pedia tric Onco                                                              logy (CPO N) (74) Certif ied Brea st Care                                                              Nurs e (CBC N) (75) Adva nced                                                              Onco logy Certif ied Nurs e Practi tioner (AOC NP) (76) Adva nced Onco logy                                                              CNS (AOC NS) (77) Ortho pedic Nurs e                                                              Certif ied (ONC ) (78) Ortho paedi c Nurs e                                                              Practi tioner (ONP ) (79) Ortho paedi c CNS                                                              (OCN S) (80) Certif ied Neon atal                                                              Inten sive Care Nurs e (RNC - NIC) (81) Pedia tric Nursi                                                              ng (PN) (82) Pedia tric CNS                                                              (PCN S) (83) Pedia tric Prim ary                                                              Care NP (PNP ) (84) Certif ied Regis tered Nurs e                                                              Anest hetist (CRN A) (85) Certif ied Nursi ng Oper ating                                                              Roo m (CNO R) (86) Certif ied Post Anest hesia Regis                                                              tered Nurs e (CPA N) (87) Certif ied RN First Assis                                                              tant (CRN FA) (88) Certif ied Amb ulator y Peria nesth                                                              esia Nurs e (CAP A) (89) Nursi ng Profe ssion al                                                              Devel opme nt (NPD ) (90) Psyc hiatri c                                                              Ment al Healt h Nurs e (PMH N) (91) Adult Psyc hiatri c and Ment al Healt h Nurs e                                                              Practi tioner Boar d Certif ied (PMH NP) (92) Adult Psyc hiatri c– Ment al Healt                                                              h CNS (PMH CNS- BC) (93) Child/ Adole scent Psyc hiatri                                                              c– Ment al Healt h CNS (PMH CNS- BC) (94) Publi c Healt h                                                              Nursi ng (PHN ) (95) Publi c/Co mmu nity Healt                                                              h CNS (PHC NS) (96) Adva nced Publi c Healt h Nursi ng                                                              Boar d Certif ied (APH N) (97) Certif ied Radi ologi cal                                                              Nurs e (CRN ) (98) Certif                                                              ied Reha bilitati on Regis tered Nurs e (CRR N) (99) Cardi ac Reha bilitati on                                                              Nursi ng (CRN ) (100) Natio nal Certif ied Scho ol                                                              Nurs e (NCS N) (101) Scho ol Nurs e Practi                                                              tioner (SNP ) (102) Certif ied Urolo gic Certif                                                              ied Nurs e (CUR N) (103) Certif ied Inpati ent Obst etrics                                                              Nurs e (RNC - OB) (104) High- Risk Perin atal                                                              Nursi ng (105) Mater nal Newb orn Nurs e                                                              (RNC - MNN ) (106) Inpati ent Obst etric Nurs                                                              e (RNC -OB) (107) Certif ied Nurs e Midwi                                                              fe (CN M) (108) Certif ied Wou nd, Osto my, Conti                                                              nenc e Nurs e (CW OCN) (109) Certif ied Wou nd Osto my                                                              Nurs e (CW ON) (110) Certif ied Wou nd Care                                                              Nurs e (CW CN) (111) Certif ied Osto my Care                                                              Nurs e (COC N) (112) Certif ied                                                              Conti nenc e Care Nursi ng (CCC N) (113) Other                                                              (8)

Answer If 5.3. Please select which of the following certifications you hold in each of your areas of specialty. Adult/Family Health Nursing - Adult Nurse Practitioner (APN) Is Selected Or 5.3. Please select which of the following certifications you hold in each of your areas of specialty. Adult/Family Health Nursing - Adult Nurse Practitioner Board Certified (APN-BC) Is Selected Or 5.3. Please select which of the following certifications you hold in each of your areas of specialty. Adult/Family Health Nursing - Family Nurse Practitioner Board Certified (FNP-BC) Is Selected Or 5.3. Please select which of the following certifications you hold in each of your areas of specialty. Adult/Family Health Nursing - Family Nurse Practitioner (FNP) Is Selected Or 5.3. Please select which of the following certifications you hold in each of your areas of specialty. Adult/Family Health Nursing - Acute Care Nurse Practitioner Board Certified (ACNP-BC) Is Selected Q5.4a 5.4a. Please provide the following information about your Advanced Practice Nurse credentials. Schedule A Certificate of Authority Expiration Date (mm/dd/yyyy) (1) Schedule II Continuing Nursing Education Date (mm/dd/yyyy) (2)

Q6.Txt SECTION VI EMPLOYMENT INFORMATION

Q6.1 6.1. Please provide the following information about your current employer. Primary Current Employer (1) Address (2) City (3) State (two letter abbreviation) (4) Zip Code (5) Phone Number where we can reach you at work (XXX-XXX-XXXX) (6) Your work E-mail Address (7) Department/Unit Name (8) Name of Immediate Supervisor/Manager (if applicable) (9) Phone Number of Immediate Supervisor/Manager (XXX-XXX-XXXX) (10) E-mail of Immediate Supervisor/Manager (11) Fax Number (12)

Q7.Txt SECTION VII CLINICAL LOCATION INFORMATION

Q7.1 7.1. Please select the clinical location where you will be precepting students from the list below. Please examine all options for your clinical location before selecting your response. If you don't see your clinical location in the list, please select "CLINICAL LOCATION IS NOT IN LIST" at the bottom of the drop down list. If you have more than one clinical location where you will be precepting students, please select for this question the location where you will precept the greatest number of students. You will be asked for information on your other clinical location(s) in subsequent questions.  Ability Center of Greater Toledo, The (13)  Adolecent & Young Adult Health Services (14)  Advanced Neurologic Assoc., Inc. (15)  Advanced Specialty Hospital (16)  AHEC (Huron, OH) (17)  AHEC (Toledo, OH) (18)  AHEC (OB/GYN) (19)  Airport Pediatrics (20)  Airport Urgent Care (21)  Alexis Medical Center (22)  All About Women (23)  Allegiance Health (24)  Allen County Health Department (25)  Allen County Health Partners (26)  Alliance for Women's Health (27)  Alliance Health Emergency (28)  American Health Network of Ohio PC (29)  Anne Grady Day Program (30)  Anthony Wayne Schools (31)  APRN Health Care Providers (32)  Area Office on Aging Northwest Ohio (33)  Arrowhead Behavioral Healthcare (34)  Arrowhead Family Physicians (35)  Arthur-Menasch MD (36)  AseraCare Hospice (37)  Associates in Women's Health (38)  Asthma and Allergy Care Center (39)  Autism Model School, The (40)  Baldwin Wallace University (41)  Barnett, Robert M.D (42)  Baton Rouge Health Services (43)  Batton Rouge Senior Health Services (44)  Bay Park Family Practice (45)  Bay Park Hospital (46)  Bay Park Hospital Emergency Department (47)  Bay Park Internal Medicine (48)  Bay Park Women's Health (49)  Bay Park Women's Services (50)  Bayshore OB/GYN (51)  Bayside Women's Center (52)  Beach House, The (54)  Beach, Patricia (CNS-Pallative Care) (55)  Beasley, Gary R. DO (56)  Bedford Family Physicians (57)  Behavioral Connections of Wood County (58)  Bellevue City Schools (59)  Bellevue Hospital (60)  Bellevue Professional Services (61)  Bixby Hospital and Emergency Department (62)  Black, Marianne (63)  Blanchard Family Physicians (64)  Blanchard Valley Health System (Hem/Onc Internal Medicine) (65)  Blanchard Valley Health System: (66)  Blanchard Valley Hospital (67)  Blanchard Valley Medical Associates (68)  Blanchard Valley Medical Association (69)  Blanchard Valley Regional Health Center (70)  Blanchard Valley Surgical Specialists (71)  Blanchard Valley Women's Care (72)  Blissfield Family Care (73)  Bluffton Physicians, Inc. (74)  Bluffton Women's Care (75)  BMC&EMC (76)  Bodie, David MD (77)  Borgess Center for Diabetes Care (78)  Bowes, Robert (OB/GYN) (79)  Bowling Green City Schools (80)  Bowling Green Clinic (81)  Bowling Green Family Care Center (82)  Bowling Green Family Physicians (83)  Bowling Green Student Health Services (84)  Boyce, Vanessa K. (85)  Boys & Girls Club of Toledo (86)  Branch Hillsdale St. Joseph Community Health Agency (87)  Bronson Lakeview Family Care (Decatur, MI) (89)  Bronson Lakeview Family Care (Paw Paw, MI) (90)  Bryan City School District (91)  C & C Health Services (92)  Camp Courageous, Inc. (93)  CardioCare Consultants (94)  Cardiology Care Assoc.Inc. (95)  Cardiology Wellness of Toledo (96)  Caughman Clinic - BVRHC (97)  Caughman Health Center (98)  Center for Child Development (99)  Center for Family Health (Jackson, MI) (100)  Center for Family Health (Toledo, OH) (101)  Center for Health Services Medicine Clinic (102)  Center for Pulmonary Medicine (103)  Central Catholic High School (104)  Central Park Pediatrics (105)  Chartier Family Medicine (106)  CHCI (107)  Cherry Street Mission (108)  Childrens Hopsital Columbus (109)  Children's Hospital Medical Center of Akron (110)  Children's Intensive Caring (111)  Clark and Kasper Inc. (112)  Clark County Combined Health District (113)  Clay-Hufford, Susan, M.D. (114)  Cleveland Clinic (115)  Cleveland Clinic Foundation, The (116)  Cleveland Clinic Loraine Family Health Center (117)  Clyde Health Clinic, The (118)  Clyde-Green Springs Schools (119)  Cockley, Mark, MD Mark Cockley MD. LLC (120)  Columbus Regional Health Care System (121)  Community Care Clinic Cedar Creek Church (122)  Community Clinic at Baton Rouge, The (123)  Community Health Partners (124)  Community Health Services (125)  Community Health Services Fremont (126)  Community Hospice Care Tiffin (127)  Community Hospitals and Wellness Centers (128)  Community Memorial Hospital (129)  Community Mercy Health Partners (130)  Comprehensive Family Practice of Michael Neverauskas DO (131)  Confer-Seeley, Kim (133)  Corporation El Ayudante De Laboatories Divination Nicaragua American Central (134)  Country Creek Family Physicians Rochester Michigan (136)  Cuyahoga County Board of Health (137)  Danbury Local School District (138)  Darlington Nursing and Rehab Center (139)  Dasani, Suresh (140)  Defiance Clinic (Fauster-Cameron Inc. dba Defiance Clinic) (141)  Defiance County Health Department (142)  Defiance Family Practice (143)  Defiance Ortho Center (144)  Defiance Regional Hospital (145)  Defiance Regional Medical Center (146)  Delta Medical Center (147)  Dermatology Assoc. (148)  Dermatology Partners (149)  DeVries, Brent, D.O. (150)  Dialysis Partners of Northwest Ohio (151)  Diller, Jonathon, MD (152)  Diroff,Corinne, CNM Associates in OB/GYN (153)  Dood, Steven (154)  Doumet, Mahdi MD (155)  Drs. Detrick and Detrick (156)  Dundee Corporate Connection (157)  Dwight Schar College of Nursing and Health Sciences (158)  East Toledo Family Center (159)  Eastern Michigan University (160)  Elmore Medical Association Inc. (161)  Elmwood Local Schools (162)  Elyria City Health Department (163)  Elyria School District Board of Education (164)  Emergency Physicians of Northwest Ohio (165)  Endocrine and Diabetes Center (166)  Endocrine and Diabetes Center for Advanced Care (167)  Endocrine Specialists, PC (Monroe, MI) (168)  Endocrine Specialists, PC (Toledo, OH) (169)  ENT Physician's, Inc. (Oregon, OH) (170)  EPNO (172)  Erie County General Health District (173)  Erie County Health Department (174)  Erie County MRDD (175)  Erie West Hospice & Palliative Care (176)  Erwin, Kermit R., MD (177)  Evercare a United Health Group Clinic (178)  Executive Court Medical Associates (179)  Fairchild, Darleen M.D. (180)  Falcon Health Center (181)  Fallen Timbers Family Physicians (182)  Family Health Riverview Center (183)  Family House; Toledo Community Service Center (185)  Family Medical Associates (186)  Family Medical Associates of Findlay (187)  Family Medical Center of Michigan (188)  Family Medical Office (189)  Family Medicine Associates (190)  Family Physicians of Lima (191)  Family Practice Clinic Erie County Health Dept. 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(693)  Toledo VA Outpatient Clinic (694)  Traboulssi, Mourhaf, MD (695)  Tubbs Jones, Stephanie OB/GYN (696)  Tuttle, Cindy FNP, RN (697)  Twin Oaks Pediatrics (698)  Unison Behavioioral Health Group (3949 Sunforest Court, Toledo, OH) (699)  Unison Behavioral Health Group (1425 Starr Avenue, Toledo, OH) (700)  University Hospitals Cleveland (701)  University of Michigan (702)  University of Michigan Medical Center (703)  University of Toledo Medical Center, The (704)  University of Toledo Physicians, LLC (705)  Upper Valley Medical Center (706)  UT Physicians Heart & Vascular (707)  UTMC - Neurology Clinic (708)  UTMC - Ryan White Clinic Infectious Diseases (709)  UTMC Acute Care (710)  UTMC Dermatology Clinic (711)  UTMC Emergency Department (712)  UTMC Endocrinology (713)  UTMC Family Medicine (714)  UTMC Geriatrics (715)  UTMC Heart and Vascular Center (716)  UTMC Infectious Disease Clinic (717)  UTMC OB/GYN Clinic (718)  UTMC Ortho Center (719)  UTMC Pain Management Clinic (720)  UTMC Urology Clinic (721)  UTMC Wound Care Clinic (722)  UTMC Oncology (723)  UTMC Pediatrics (724)  UTMC-Surgery Cardic Thoracic Surgery (725)  VA Ann Arbor Healthcare System (726)  VA Clinic Toledo (727)  VA Health Systems Cardiology (728)  Van Kainen, Barbara (729)  Van Wert Medical Services (730)  Van Wert Visiting Nurse Association (731)  Vannuyen, Jackie, M.D. OB/GYN (732)  Vascular Professionals Inc. 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(755)  Wildwood Family Practice (756)  Wildwood Surgical Center (757)  Willard City Schools (758)  Wilson Care, LLC (759)  Wilson Memorial Hospital (760)  Wishing Well Pediatrics (761)  Wohlwend Family Practice, Inc. (762)  Women's & Children's Center (763)  Women's Adolescent Health (764)  Women's Answer, A (765)  Women's Family Service (766)  Women's Health Center (767)  Women's Health Clinic Sandusky County (768)  Women's Health for Life (Findlay, OH) (769)  Women's Health for LIfe Inc. (Lima, OH) (770)  Women's Health Specialists (771)  Women's Place, A (772)  Wonderly, Mary MD (773)  Wood County Committee on Aging (774)  Wood County Community Health & Wellness Center (775)  Wood County Emergency Department (776)  Wood County Health Department (777)  Wood County Health District (778)  Wood County Hospital (779)  Wood County Medical Assoc. (755 Haskins Road, Bowling Green, OH) (780)  Wood County Medical Associates (970 W. Wooster Street, Bowling Green, OH) (781)  Wood County Pediatrics (782)  Wood County Women's Care (783)  Wood Health Corporation (784)  Wood, Robert F., MD (785)  Woodley Park Internal Medicine (786)  Woodville Family Practice (787)  Wright State University (788)  WW Knight Family Practice (789)  YWCA of Greater Toledo (790)  Zepf Center (791)  Zubair, Iram, M.D. (792)  CLINICAL LOCATION IS NOT IN LIST (11)

Answer If 7.1. Please select your clinical location from the list below. Please examine all options for your clinical location before selecting your response. If you don't see your clinical location in th... CLINICAL LOCATION IS NOT IN LIST Is Selected Q7.1a 7.1a. Please provide the name of your clinical location in the box below.

Q7.2 7.2. Please provide the following information about your clinical location. Name of Unit/Department (2) Address (3) City (4) State (two letter abbreviation) (5) Zip Code (6) Phone Number of Clinical Location (XXX-XXX-XXXX) (7)

Q7.3 7.3. Is this clinical location owned by a parent agency?  Yes (1)  No (2)

Answer If Is the clinical site/agency/office owned by a parent agency? Yes Is Selected Q7.3a 7.3a. Please provide the name of the parent organization. Name of Parent Organization (1) Address (2) City (3) State (two letter abbreviation) (4) Zip Code (5) Phone Number ((XXX-XXX-XXXX)) (6)

Q7.4 7.4. Do you have a second clinical location where you will be precepting students?  Yes (1)  No (2) If No Is Selected, Then Skip To End of Block

Q7.5 7.5. Please select your second clinical location from the list below. Please examine all options for your clinical location before selecting your response. If you don't see your clinical location in the list, please select "CLINICAL LOCATION IS NOT IN LIST" at the bottom of the drop down list.  Ability Center of Greater Toledo, The (13)  Adolecent & Young Adult Health Services (14)  Advanced Neurologic Assoc., Inc. (15)  Advanced Specialty Hospital (16)  AHEC (Huron, OH) (17)  AHEC (Toledo, OH) (18)  AHEC (OB/GYN) (19)  Airport Pediatrics (20)  Airport Urgent Care (21)  Alexis Medical Center (22)  All About Women (23)  Allegiance Health (24)  Allen County Health Department (25)  Allen County Health Partners (26)  Alliance for Women's Health (27)  Alliance Health Emergency (28)  American Health Network of Ohio PC (29)  Anne Grady Day Program (30)  Anthony Wayne Schools (31)  APRN Health Care Providers (32)  Area Office on Aging Northwest Ohio (33)  Arrowhead Behavioral Healthcare (34)  Arrowhead Family Physicians (35)  Arthur-Menasch MD (36)  AseraCare Hospice (37)  Associates in Women's Health (38)  Asthma and Allergy Care Center (39)  Autism Model School, The (40)  Baldwin Wallace University (41)  Barnett, Robert M.D (42)  Baton Rouge Health Services (43)  Batton Rouge Senior Health Services (44)  Bay Park Family Practice (45)  Bay Park Hospital (46)  Bay Park Hospital Emergency Department (47)  Bay Park Internal Medicine (48)  Bay Park Women's Health (49)  Bay Park Women's Services (50)  Bayshore OB/GYN (51)  Bayside Women's Center (52)  Beach House, The (54)  Beach, Patricia (CNS-Pallative Care) (55)  Beasley, Gary R. DO (56)  Bedford Family Physicians (57)  Behavioral Connections of Wood County (58)  Bellevue City Schools (59)  Bellevue Hospital (60)  Bellevue Professional Services (61)  Bixby Hospital and Emergency Department (62)  Black, Marianne (63)  Blanchard Family Physicians (64)  Blanchard Valley Health System (Hem/Onc Internal Medicine) (65)  Blanchard Valley Health System: (66)  Blanchard Valley Hospital (67)  Blanchard Valley Medical Associates (68)  Blanchard Valley Medical Association (69)  Blanchard Valley Regional Health Center (70)  Blanchard Valley Surgical Specialists (71)  Blanchard Valley Women's Care (72)  Blissfield Family Care (73)  Bluffton Physicians, Inc. (74)  Bluffton Women's Care (75)  BMC&EMC (76)  Bodie, David MD (77)  Borgess Center for Diabetes Care (78)  Bowes, Robert (OB/GYN) (79)  Bowling Green City Schools (80)  Bowling Green Clinic (81)  Bowling Green Family Care Center (82)  Bowling Green Family Physicians (83)  Bowling Green Student Health Services (84)  Boyce, Vanessa K. (85)  Boys & Girls Club of Toledo (86)  Branch Hillsdale St. Joseph Community Health Agency (87)  Bronson Lakeview Family Care (Decatur, MI) (89)  Bronson Lakeview Family Care (Paw Paw, MI) (90)  Bryan City School District (91)  C & C Health Services (92)  Camp Courageous, Inc. (93)  CardioCare Consultants (94)  Cardiology Care Assoc.Inc. (95)  Cardiology Wellness of Toledo (96)  Caughman Clinic - BVRHC (97)  Caughman Health Center (98)  Center for Child Development (99)  Center for Family Health (Jackson, MI) (100)  Center for Family Health (Toledo, OH) (101)  Center for Health Services Medicine Clinic (102)  Center for Pulmonary Medicine (103)  Central Catholic High School (104)  Central Park Pediatrics (105)  Chartier Family Medicine (106)  CHCI (107)  Cherry Street Mission (108)  Childrens Hopsital Columbus (109)  Children's Hospital Medical Center of Akron (110)  Children's Intensive Caring (111)  Clark and Kasper Inc. (112)  Clark County Combined Health District (113)  Clay-Hufford, Susan, M.D. (114)  Cleveland Clinic (115)  Cleveland Clinic Foundation, The (116)  Cleveland Clinic Loraine Family Health Center (117)  Clyde Health Clinic, The (118)  Clyde-Green Springs Schools (119)  Cockley, Mark, MD Mark Cockley MD. LLC (120)  Columbus Regional Health Care System (121)  Community Care Clinic Cedar Creek Church (122)  Community Clinic at Baton Rouge, The (123)  Community Health Partners (124)  Community Health Services (125)  Community Health Services Fremont (126)  Community Hospice Care Tiffin (127)  Community Hospitals and Wellness Centers (128)  Community Memorial Hospital (129)  Community Mercy Health Partners (130)  Comprehensive Family Practice of Michael Neverauskas DO (131)  Confer-Seeley, Kim (133)  Corporation El Ayudante De Laboatories Divination Nicaragua American Central (134)  Country Creek Family Physicians Rochester Michigan (136)  Cuyahoga County Board of Health (137)  Danbury Local School District (138)  Darlington Nursing and Rehab Center (139)  Dasani, Suresh (140)  Defiance Clinic (Fauster-Cameron Inc. dba Defiance Clinic) (141)  Defiance County Health Department (142)  Defiance Family Practice (143)  Defiance Ortho Center (144)  Defiance Regional Hospital (145)  Defiance Regional Medical Center (146)  Delta Medical Center (147)  Dermatology Assoc. (148)  Dermatology Partners (149)  DeVries, Brent, D.O. (150)  Dialysis Partners of Northwest Ohio (151)  Diller, Jonathon, MD (152)  Diroff,Corinne, CNM Associates in OB/GYN (153)  Dood, Steven (154)  Doumet, Mahdi MD (155)  Drs. Detrick and Detrick (156)  Dundee Corporate Connection (157)  Dwight Schar College of Nursing and Health Sciences (158)  East Toledo Family Center (159)  Eastern Michigan University (160)  Elmore Medical Association Inc. (161)  Elmwood Local Schools (162)  Elyria City Health Department (163)  Elyria School District Board of Education (164)  Emergency Physicians of Northwest Ohio (165)  Endocrine and Diabetes Center (166)  Endocrine and Diabetes Center for Advanced Care (167)  Endocrine Specialists, PC (Monroe, MI) (168)  Endocrine Specialists, PC (Toledo, OH) (169)  ENT Physician's, Inc. (Oregon, OH) (170)  EPNO (172)  Erie County General Health District (173)  Erie County Health Department (174)  Erie County MRDD (175)  Erie West Hospice & Palliative Care (176)  Erwin, Kermit R., MD (177)  Evercare a United Health Group Clinic (178)  Executive Court Medical Associates (179)  Fairchild, Darleen M.D. (180)  Falcon Health Center (181)  Fallen Timbers Family Physicians (182)  Family Health Riverview Center (183)  Family House; Toledo Community Service Center (185)  Family Medical Associates (186)  Family Medical Associates of Findlay (187)  Family Medical Center of Michigan (188)  Family Medical Office (189)  Family Medicine Associates (190)  Family Physicians of Lima (191)  Family Practice Clinic Erie County Health Dept. (192)  Family Practice of Hillsdale (193)  Family Practice of Toledo (195)  Fauster-Cameron, Inc. dba Defiance Clinic (196)  Fay, Lorraine, MD (198)  Federman, Douglas (199)  Felix, Charles G., M.D. (200)  Figy, Rex Neil, M.D. Office of (201)  Fireland Physician Group Family Practice (SAHEC) (202)  Firelands Physician Group Urgent Care (Clyde, OH) (203)  Firelands Physician Group Urgent Care (Sandusky, OH) (204)  Firelands Physicians Group (205)  Firelands Regional Medical Center (206)  Fisher Titus Care (207)  Fisher Titus Medical Care LLC (East Milan, OH) (208)  Fisher Titus Medical Care LLC (Wakeman, OH) (209)  Flat Rock Physicians (210)  Flower Hospital (211)  Flower Hospital Family Residency (212)  Fondessy, Terrence MD (213)  Forrest, Todd DO (214)  Fort Hays State University (215)  Fort Meigs Family Physicians (216)  Fostoria City Schools (217)  Fostoria Community Hospitals (218)  Fostoria Family Medicine (219)  Foundation Park Care Center (220)  Franklin Park Pediatrics (221)  Fremont Board of Education (222)  Fremont Family Medicine (223)  Fremont Medical Center (224)  Fremont Medical Clinic (225)  Fremont Memorial Hospital (226)  Fremont Walk In Medical Center (227)  Ft. Meigs Family Physicians (228)  Ft. Meigs Perrysburg Family Practice (229)  Fulton County Health Center (230)  Fulton County Health Center Emergency Department (231)  Fulton County Health Department (232)  Gase, Andrew MD Family Practice Office (233)  Geauga County General Health District (235)  Geisler, John MD (236)  Gibbs, Terry MD (237)  Gibsonburg Exempted Village School District (238)  Girl Scouts of Western Ohio (240)  Gottfried, James Allen (241)  Gray, Wm. J. M.D. (Morence, MI) (242)  Gray, Wm. J. M.D., Inc. (Blissfield, MI) (243)  Graystone Family Practice (244)  Great Lakes Medical Services (245)  Great Lakes Urgent Care (246)  Grillis, Michael D.O. (247)  Gross, Thomas M.D. (248)  Gutowski, Scott R. (249)  H. C. Providers, LLC (250)  Hackl, Pamela DO (251)  Hagerman Family Physicians (252)  Hancock County Health Department (253)  Harbor Behavioral Healthcare (254)  Harbor Family Practice (255)  Harwani, Ashok N., M.D. (256)  Health Partners of Western Ohio (257)  Health Specialists of Lenawee, P.C. (259)  Heartland - Holly Glen (260)  Heartland Hospice Services (261)  Heartland of Oregon (262)  Heartland of Perrysburg (263)  Heartland of Waterville (264)  Helping Hands of St. Louis (265)  Henry County Health Department (266)  Henry County Hospital (267)  Henry County Senior Center (268)  Henry Ford Wyandotte Hospital (269)  Heritage Healthcare Services (270)  Heritage Primary Care & Sports Medicine (271)  Hickman Cancer Center - Flower Memorial Hospital (272)  Hiestand, John, MD (273)  Hillsdale Pulmonary Critical Care (274)  Hilty Memorial Home (275)  HOA Cancer Center (276)  Hospice of Northwest Ohio (277)  Hospice of Western Reserve (278)  Hospice The-Caring-Way of Williams and Fulton Counties (279)  Hull, Charles MD (281)  HungKuang University (Grant) (282)  HungKuang University (Clinical Ageement) (283)  Huron County General Health District (284)  Huron Valley Neurology (285)  Husain, Syed Zakir, MD (286)  Independent Emergency Physicians (287)  Infectious Disease Associates (288)  Infectious Disease Luis Ernesto Jauregui-Peredo, M.D. (289)  Interim Healthcare (291)  Intermed Associates Inc. (292)  Internal Medicine Associates of S. E. Michigan (Ypsilanti, MI) (293)  Internal Medicine Associates of Southeast Michigan P.C. (Adrian, MI) (294)  Jauregui, Luis MD (296)  Jensen, Donna D.O. (297)  Johnson, Katherine, M.D. (298)  Joint Township District Memorial Hospital (299)  Jonathan Diller MD Inc (300)  Jonathan E. Pasko, M.D., PC (301)  Joy-Southfield Community Development Corporation, Inc. (302)  Juvenile Justice Clinic (304)  Kabir, Abdul, MD (305)  Kakarala, Prasad M.D. (306)  Kalus, Michael, MD ClevelandClinic (307)  Karamali, Adil M., M.D. Cardiocare (308)  Katz, Dr. Laura Alyce OB/GYN (309)  Kelin, Elizabeth, FNP, RN (310)  Kessler, Nancy MD (311)  Kidney and HTN Associates (312)  Kingston Care Center of Sylvania (313)  Kirk R. Davis, D.O. (314)  Komorowski, Frank S. MD LLC (315)  Lake County General Health District (317)  Lake Erie Nephrology & HTN (318)  Lake Local Schools (319)  Lampe, Teresa J. MD (320)  Lateef, Humaira MD., Harroun Rd. Family Phys. (321)  Laurels of Toledo ,The (322)  Liberty Center Schools (323)  Lima Family Care (324)  Lima Group Family Physicians (325)  Lima Memorial Health System (326)  Lima Memorial Hospital (327)  Little Clinic, The (328)  Little Sisters of the Poor (329)  Locust Pediatric Care Group, Inc. (330)  Lopez, Nicholas M., M.D. (331)  Lorain County Community College (332)  Lott Hill Adult Service Center (333)  Lourdes University (334)  Lucas County Board of Mental Retardation and Developmental Disabilities (335)  Lucas County Corrections Center (337)  Lucas County Health Dept. Nurse Midwifery and Women's Health (338)  Lucas County Health Dept. (339)  Lucas County Juvenile Detention Center (340)  Lutheran Homes Society Community Services (341)  Lutheran Village at Wolf Creek (342)  Magruder Hospital (343)  Maludy, Jeffrey M.D. (344)  Mansfield/Ontario/Richland County Health Department (345)  Mansion Street Women's Health PLLC (346)  Maple Creek Bucyrus Community Physicians (347)  Margaret Hunt Senior Center (348)  Marshall & Knieriem Family Medicine (349)  Marshall Internal & Family Medicine (Marshall, MI) (350)  Marshall Internal and Family (Tekonsha, MI) (351)  Martz and Martin Family Practice (352)  Masserant, John M.D. (353)  Mather, Arun D. MD (354)  Mattison, Timothy J. MD WellCare Physician Group (355)  Maumee Bay Family Practice (356)  Maumee Bay Obstetrics and Gynecology (357)  Maumee Bay Pediatrics (358)  Maumee Medical Partners LTD (359)  Maumee OB/GYN (360)  Maumee Pediatric Association (361)  MaxWell Clinic, The (362)  Medtapp Grant (363)  MEDF Physician's Corportation OB/GYN (364)  Memorial Health Care Systems (365)  Memorial Hospital (366)  Mercy Children's Hospital Foundation (367)  Mercy Children's Hospital Pediatric GI (368)  Mercy Children's Hospital Pediatric Urology (369)  Mercy College of Northwest Ohio (370)  Mercy Congenital Heart Specialists (371)  Mercy Family Physicians (372)  Mercy Family Physicians Point Shoreland (373)  Mercy Family Practice Perrysburg (374)  Mercy Family Practice Tiffin (375)  Mercy Health Center of Carroll County (376)  Mercy Hospital of Tiffin (377)  Mercy Medical Center (378)  Mercy Medical Center of Tuscarawas Cty. (379)  Mercy Memorial Hospital Emergency Department (380)  Mercy Memorial Hospital Monroe (381)  Mercy OB/GYN Associates (383)  Mercy OB/GYN Associates Perrysburg (384)  Mercy Orthopedic and Sports Medicine (Perrysburg, OH) (385)  Mercy Orthopedics & Sports Medicine (Carrollton, OH) (386)  Mercy Pediatric Association (387)  Mercy Post Acute (388)  Mercy Primary Care (389)  Mercy Primary Care Associates (Lorain, OH) (390)  Mercy Primary Care Associates (Swanton, OH) (391)  Mercy Regional Hospital (393)  Mercy St. Anne Hospital (394)  Mercy St. Charles Hospital (395)  Mercy St. Vincent Children's Hospital (396)  Mercy St. Vincent Medical Center (397)  Mercy Tiffin Hospital (398)  Metamora Family Practice (399)  Metro Health Medical Center (400)  Metrohealth Broadway (402)  Midwest Community Health Associates (403)  Midwest Community Health Association-BAHEC (404)  Midwest Community Health Group (405)  Midwest Community Health Associates (406)  Midwest Community Health/Parkview Physicians OB/GYN (407)  Mitchell Dermatology (408)  MK & SS Ahmed, MDs, Inc. (409)  MN Angels Adult & Pediatric Care (Bowling Green, OH) (410)  MN Angels Adult & Pediatric Care (Toledo, OH) (411)  Monclova Road Pediatrics (412)  Monroe County Community College (413)  Monroe County Sheriff's Department (414)  Monroe Health Center (415)  Monroe Mercy Hospital - Pediatric ED (416)  Montpelier Medical Center (417)  Nadaud, Mark C. D.O. (418)  Nationwide Children's Hospital (419)  Neighborhood Health Associates (420)  Neighborhood Health Association (421)  Nephrology Associates of Toledo (422)  New Beginnings Pediatrics (Maumee, OH) (423)  New Beginnings Pediatrics (Norwalk, OH) (424)  New Hanover County Health Department (425)  Newport Internal Medicine Newport Michigan (427)  Niese, Diane K. (428)  NOMS - Sandusky Northern Ohio Medical Specialists (429)  NOMS Family Practice (431)  NOMS Internal Medicine (432)  NOMS (OB/GYN) (433)  Nordonia Hills Clinic (Internal Medicine) (434)  North Central Women's Health (436)  North Coast Professionals Firelands Physician Group (437)  North Ohio Heart Inc. (Lorain, OH) (439)  North Ridgeville City Schools (440)  Northcoast Behavioral Health Care (441)  Northern Ohio Medical Specialists (Sandusky, OH) (442)  Northern Ohio Medical Specialists Urgent Care (443)  Northwest ENT Consultants (435)  Northwest Ohio Cardiology Consultants (Toledo, OH) (445)  Northwest Ohio Cardiology Consultants (Sandusky, OH) (446)  Northwest Ohio Center for Urogynecology and Women's Health (447)  Northwest Ohio Emergency Services (448)  Northwest Ohio Gastroenterology Associates (449)  Northwest Ohio Gastroenterology (450)  Northwest Ohio Health Partners (451)  Northwest Ohio OB/GYN (452)  Northwest Ohio Orthopedics and Sports (Bluffton, OH) (454)  Northwest Ohio Orthopedics-NOW (455)  Northwest Ohio Orthpedics & Sports Medicine, Inc (Findlay, OH) (456)  Northwest Ohio Partners in Women's Health (457)  Northwest Ohio Primary Care Physicians/Rossford Family Practice (458)  Northwest Ohio Psychiatric Hospital (Clyde, OH) (459)  Northwest Ohio Psychiatric Hospital (Toledo, OH) (460)  Northwest Ohio Urgent Care (Maumee, OH) (461)  Northwest Ohio Urgent Care (Sandusky, OH) (462)  Northwest Ohio Urgent Care, Inc. Network LLC (463)  Northwest Primary Care Physicians (Maumee, OH) (464)  Northwest Primary Care, Inc. (Clyde, OH) (465)  Northwest State Community College (466)  Northwest Surgical Specialists Inc. (467)  Northwood Local Schools (468)  Nucklos, Ruby, M.D. Ruppert Med. Center (469)  Nuga Pediatrics (470)  NWO Urgent Care/Bedford Urgent Care (471)  Office of Todd Robert Forrest,D.O. (472)  Ohio Heart and Vascular Consultants (473)  Ohio Northern University (474)  Ohio University School of Nursing (475)  OhioHealth Corporation (476)  OMNI Health Services, Ltd. (477)  Onslow Memorial Hospital (478)  Optum Clinical Services (479)  Orchard Villa (Cleveland, OH) (480)  Orchard Villa (Oregon, OH) (481)  Oregon Clinic, Inc. (2841 Munding, Oregon, OH) (482)  Oregon Clinic, Inc. (3841 Navarre Ave, Oregon, OH) (483)  Oregon Urgent Care and Family Practice (484)  Orra, Abdul M. D.O. (485)  Osowik, Rosemarie A., M.D. (486)  Owens Community College (30335 Oregon Rd., Perrysburg, OH) (488)  Owens State Community College Nursing Department (489)  Pappas, Angela Marie NP (490)  Pappas, S. John, M.D. (491)  Parker, Michael P., M.D. (492)  Parkside Care Corporation (493)  Parkside Surgery Center (494)  Parkview Phsycians Group Montpelier (495)  Parkview Physicians Group (496)  Partners in Primary Care (Montpelier, OH) (497)  Partners in Primary Care (Sandusky, OH) (498)  Pasko, Jonathan MD, PC (499)  Paulding County Hospital (500)  Paulding Exempted Village Schools (501)  Pediaticare Assoc. (502)  Pediatric Center, Inc. (503)  Pediatric Center, The (Adrian, MI) (504)  Pediatric Center, The (Lambertville, MI) (505)  Pediatric Center, The (Oregon, OH) (506)  Pediatric Center, The (Toledo, OH) (507)  Pediatric Fast Track/Mercy Memorial Hospital (508)  Pediatric Pulmonary Specialists (3400 Meijer Dr, Toledo, OH) (509)  Pediatric Pulmonary Specialists (2222 Cherry St., Toledo, OH) (510)  Pediatricare Associates (Lima, OH) (511)  Pediatricare Associates (Toledo, OH) (512)  Pediatrics at Center for Health Services (513)  Pediatrics of Lima (514)  Peninsula Medical Center (515)  Penta Career Center (516)  Peron, Slavador MD (517)  Perrysburg Family Physicians (518)  Perrysburg Fort Meigs Family Practice (519)  Perrysburg Pediatrics (520)  Personal Touch Deliveries (Sylvania, OH) (521)  Personal Touch Deliveries (Tiffin, OH) (522)  Physician Plus/Blanchard Valley Health System (523)  Physicians Plus Urgent Care (524)  Pickaway Health Services (Findlay, OH) (525)  Pickaway Health Services (Laurelville, OH) (526)  Planned Parenthood (Columbus, OH) (527)  Planned Parenthood (Toledo, OH) (528)  Port Clinton City School District (529)  Port Sylvania Family Physicians (530)  Power, Kenneth, M.D. (531)  PPG Adult Medicine Clinic (532)  PPG Harroun Road Family Physicians (533)  Premier Women's Health (534)  Premiere Family Practice (Massillon, OH) (535)  Premiere Family Practice (Westlake, OH) (536)  Prenancy Center of Greater Toledo, The (537)  Primary Care Associates (538)  Primary Care Partners of The Toledo Clinic (539)  Primary Care Partners (540)  ProMedica After Hours (541)  ProMedica Continuing Care Services Corporation (542)  ProMedica Health Systems, Inc (543)  ProMedica Hematology Oncology (547)  ProMedica Occuhealth Center for Health Services (Sylvania, OH) (548)  Promedica Occuhealth Center for Health Services (Toledo, OH) (549)  ProMedica Perrysburg Pediatrics (550)  ProMedica Physician Group, Inc. (551)  ProMedica Physicians & Continuum Services (552)  ProMedica Physicians Cardiology (553)  ProMedica Physicians Corporation (554)  ProMedica Physicians Morenci (555)  Promedica Urgent Care (556)  Puckett, Sarah, D.O. Drs. Puckett and Vannyen (OB/GYN) (557)  Pulmonary and Critical Care Specialists (558)  Putnam County Health Dept. (559)  Putnam County Primary Care (560)  R. W. Minick Medical Center (561)  Ragothaman, Krishna, M.D. (562)  Rao, Upamaka, M.D. (563)  Reconstructive and Aesthetic Surgeons (564)  Regency Park Clinic (565)  Regional Obstetrical Consultants (566)  Renal Services of Toledo Inc. (568)  Rescue Crisis Center (569)  Rescue Mental Health (570)  Respiratory & Infectious Disease,Inc. (571)  Rhodes State College (572)  Rinehart Family Health LLC (573)  River Road Family Physicians (574)  Rivercrest OB/GYN ProMedica aka/Wellcare Physicians Group (575)  Riverview Family Health (Perrysburg, OH) (577)  Riverview Family Health (Riverview, MI) (578)  Romius Institute Urology (579)  Rossford Family Practice (580)  Rossford Schools (581)  S.A.I.L., Inc. (582)  Sandusky Board of Developmental Disabilities (583)  Sandusky Career Center (584)  Sandusky City Schools and Sandusky Career Center Office of Career-Technical and Adult Education (585)  Sandusky County Health Department (588)  Sandusky Family Practice (589)  Sandusky Pediatricians (590)  Sanjiv Josh, M.D. (591)  Scheer, Marvin, M.D. (592)  Scherer, Michael D.O. (593)  Secure Care, INC. (594)  Seneca County General Health District (595)  Shaker Heights City Health Department (596)  Shalini Singh, D.O. (597)  Sherwood Medical Center (598)  Singh, Parminder, M.D. (599)  Smolinski, Stephen M.D. Ph.D. (600)  Snider, Mark M.D. Family Practice (601)  Sood, Rama, M.D. (602)  South Pointe Hospital Cleveland Clinic (603)  South Toledo Internist (604)  South Toledo Pediatric Association (605)  Southern Care Toledo (606)  Southwest General Health Center (607)  Spencerville Local Schools (608)  Spino Sandra (609)  Spring Forest Family Physicians (610)  Springfield City Schools (611)  St Clare Commons (612)  St. Anne's Mercy Hospital (613)  St. Catherine's School (614)  St. Charles Emergency Department (615)  St. Francis de Sales High School (616)  St. George Urgent Care (Perrysburg, OH) (617)  St. George Urgent Care (Maumee, OH) (618)  St. John Baptist School (619)  St. John Jesuit High School (620)  St. John West Shore Hospital (621)  St. Luke's Hospital (622)  St. Luke's Hospital/ UT Family Medicine Residency (623)  St. Paul's Community Center (624)  St. Paul's Lutheran Church (625)  St. Riita's Hospital (626)  St. Rita's Medical Center (627)  St. Rita's Medical Center Emergency Department (628)  St. Rita's Professional Services (629)  St. Rita's Putnam County Ambulatory Care (630)  St. Rita's Urgent Care (631)  St. Vincent (Mercy St. V's) (632)  St. Vincent Charity Hospital-Ctr.for Vasc. Health (633)  St. Vincent Family Care Center (634)  St. Vincent Mercy Medical Center (635)  Stafford/Legacy Services Orchard Villa (636)  Stalter, Marvin D., M.D. (637)  Steele, D.O. (638)  Stein Hospice (Port Clinton, OH) (639)  Stein Hospice (Sandusky, OH) (640)  Strzesynski, Caroline (641)  Summa Akron City and St. Thomas Hospitals (642)  Sunforest OB/GYN (643)  Sunset Retirement Communities (644)  Surgery Center at Regency Park (645)  Swan Creek Health Care Center (646)  Swann, Gary F., DO OB-GYN (647)  Swanton Family Physicians (648)  Swartz, Jeffery, MD NWOCPCP (649)  Sylvan Oak Family Physicians (650)  Sylvania Adult and Pediatric Medicine (651)  Sylvania Family Physicians (Toledo, OH) (652)  Sylvania Family Physicians, LLC (Sylvania, OH) (653)  Sylvania Schools (654)  Sylvania Urgent Care (655)  Take Care Health System (656)  Tecumseh Family Practice (657)  Tender Touch Pediatrics, A (658)  Terra Community College (Tecumseh, MI) (659)  Terra Community College (Toledo, OH) (660)  Tharp, Kathleen R., CNP (661)  Timberstone Family Physicians (2150 W. Central Ave, Toledo, OH) (662)  Timberstone Family Physicians (4411 Holland-Sylvania Rd, Toledo, OH) (663)  Toledo Cardiology Consultants (664)  Toledo Center for Health Services (5210 Renwyck Dr., Toledo, OH) (665)  Toledo Center for Health Services (2150 W. Central Ave, Toledo, OH) (793)  Toledo Children's Heart Center (667)  Toledo Children's Hospital ( 4411 Holland Sylvania Ave, Toledo, OH) (668)  Toledo Children's Hospital (2142 N. Cove Blvd, Toledo, OH) (669)  Toledo Children's Primary Care (670)  Toledo Clinic IM/Endocrinology (671)  Toledo Clinic Cardiology (672)  Toledo Clinic General Surgery (673)  Toledo Clinic Ambulatory Surgery Center, The (674)  Toledo Clinic Cancer Center (675)  Toledo Clinic Dermatology/Dermtologic Surgery (676)  Toledo Clinic Family Practice, The (677)  Toledo Clinic Neurology (678)  Toledo Clinic Family Medicine (679)  Toledo Clinic Nephrology (680)  Toledo Clinic, The (681)  Toledo Clinic/Hematology-Oncology (683)  Toledo Community Service Center (684)  Toledo Hospital (685)  Toledo Hospital Emergency Department (686)  Toledo Internal Medical Specialists (2142 N. Cove Blvd., Toledo, OH) (687)  Toledo Internal Medical Specialists Inc. (5270 Renwyck Dr, Toledo, OH) (688)  Toledo Internal Medicine Specialists (689)  Toledo Lucas County Health Department (690)  Toledo Peds, Inc. (691)  Toledo Public Schools (692)  Toledo Radiological Group Assoc. Inc. (693)  Toledo VA Outpatient Clinic (694)  Traboulssi, Mourhaf, MD (695)  Tubbs Jones, Stephanie OB/GYN (696)  Tuttle, Cindy FNP, RN (697)  Twin Oaks Pediatrics (698)  Unison Behavioioral Health Group (3949 Sunforest Court, Toledo, OH) (699)  Unison Behavioral Health Group (1425 Starr Avenue, Toledo, OH) (700)  University Hospitals Cleveland (701)  University of Michigan (702)  University of Michigan Medical Center (703)  University of Toledo Medical Center, The (704)  University of Toledo Physicians, LLC (705)  Upper Valley Medical Center (706)  UT Physicians Heart & Vascular (707)  UTMC - Neurology Clinic (708)  UTMC - Ryan White Clinic Infectious Diseases (709)  UTMC Acute Care (710)  UTMC Dermatology Clinic (711)  UTMC Emergency Department (712)  UTMC Endocrinology (713)  UTMC Family Medicine (714)  UTMC Geriatrics (715)  UTMC Heart and Vascular Center (716)  UTMC Infectious Disease Clinic (717)  UTMC OB/GYN Clinic (718)  UTMC Ortho Center (719)  UTMC Pain Management Clinic (720)  UTMC Urology Clinic (721)  UTMC Wound Care Clinic (722)  UTMC Oncology (723)  UTMC Pediatrics (724)  UTMC-Surgery Cardic Thoracic Surgery (725)  VA Ann Arbor Healthcare System (726)  VA Clinic Toledo (727)  VA Health Systems Cardiology (728)  Van Kainen, Barbara (729)  Van Wert Medical Services (730)  Van Wert Visiting Nurse Association (731)  Vannuyen, Jackie, M.D. OB/GYN (732)  Vascular Professionals Inc. Clark and Kasper (733)  Victory Center (734)  Waldron, Laura, M.D. (735)  Walk In Urgent Care (Bowling Green, OH) (736)  Walk-In Urgent Care (Tiffin, OH) (737)  Walk-In Urgent Care (Toledo, OH) (738)  Washington Local Schools (739)  Waterford Commons (740)  Waterville Family Physicians (741)  Webb-Smith, Frances, M.D. (742)  Wellcare Physicians Group, LLC (743)  Wellcare Physicians of Promedica (744)  West Central Med. Group (745)  West Central Ohio Cardiology, Inc. (746)  West Ohio Family Physicians (Maumee, OH) (747)  West Ohio Family Physicians (Wauseon, OH) (748)  West Ohio Orthopedics (749)  West Toledo Internal Medicine (Sylvania, OH) (750)  West Toledo Internal Medicine Associates (Wauseon, OH) (751)  Westfield OB/GYN (752)  Westgate Medical Group (753)  Wexler, Wendy, M.D. (754)  White, Benjamin, D.O. (755)  Wildwood Family Practice (756)  Wildwood Surgical Center (757)  Willard City Schools (758)  Wilson Care, LLC (759)  Wilson Memorial Hospital (760)  Wishing Well Pediatrics (761)  Wohlwend Family Practice, Inc. (762)  Women's & Children's Center (763)  Women's Adolescent Health (764)  Women's Answer, A (765)  Women's Family Service (766)  Women's Health Center (767)  Women's Health Clinic Sandusky County (768)  Women's Health for Life (Findlay, OH) (769)  Women's Health for LIfe Inc. (Lima, OH) (770)  Women's Health Specialists (771)  Women's Place, A (772)  Wonderly, Mary MD (773)  Wood County Committee on Aging (774)  Wood County Community Health & Wellness Center (775)  Wood County Emergency Department (776)  Wood County Health Department (777)  Wood County Health District (778)  Wood County Hospital (779)  Wood County Medical Assoc. (755 Haskins Road, Bowling Green, OH) (780)  Wood County Medical Associates (970 W. Wooster Street, Bowling Green, OH) (781)  Wood County Pediatrics (782)  Wood County Women's Care (783)  Wood Health Corporation (784)  Wood, Robert F., MD (785)  Woodley Park Internal Medicine (786)  Woodville Family Practice (787)  Wright State University (788)  WW Knight Family Practice (789)  YWCA of Greater Toledo (790)  Zepf Center (791)  Zubair, Iram, M.D. (792)  CLINICAL LOCATION IS NOT IN LIST (11)

Answer If 7.5. Please select your second clinical location from the list below.  Please examine all options for your clinical  location before selecting your response.  If you don't ... CLINICAL LOCATION IS NOT IN LIST Is Selected Q7.5a 7.5a. Please provide the name of your second clinical location in the box below.

Q7.6 7.6. Please provide the following information about your second clinical location. Name of Unit/Department (2) Address (3) City (4) State (two letter abbreviation) (5) Zip Code (6) Phone Number of Clinical Location (XXX-XXX-XXXX) (7)

Q7.7 7.7. Is your second clinical location owned by a parent agency?  Yes (1)  No (2)

Answer If 7.7. Is your second clinical location owned by a parent agency? Yes Is Selected Q7.7a 7.7a. Please provide the name of the parent organization for your second clinical location. Name of Parent Organization (1) Address (2) City (3) State (two letter abbreviation) (4) Zip Code (5) Phone Number ((XXX-XXX-XXXX)) (6)

Q7.8 7.8. Do you have a third clinical location?  Yes (1)  No (2) If No Is Selected, Then Skip To End of Block

Q7.9 7.9. Please select your third clinical location from the list below. Please examine all options for your clinical location before selecting your response. If you don't see your clinical location in the list, please select "CLINICAL LOCATION IS NOT IN LIST" at the bottom of the drop down list.  Ability Center of Greater Toledo, The (13)  Adolecent & Young Adult Health Services (14)  Advanced Neurologic Assoc., Inc. (15)  Advanced Specialty Hospital (16)  AHEC (Huron, OH) (17)  AHEC (Toledo, OH) (18)  AHEC (OB/GYN) (19)  Airport Pediatrics (20)  Airport Urgent Care (21)  Alexis Medical Center (22)  All About Women (23)  Allegiance Health (24)  Allen County Health Department (25)  Allen County Health Partners (26)  Alliance for Women's Health (27)  Alliance Health Emergency (28)  American Health Network of Ohio PC (29)  Anne Grady Day Program (30)  Anthony Wayne Schools (31)  APRN Health Care Providers (32)  Area Office on Aging Northwest Ohio (33)  Arrowhead Behavioral Healthcare (34)  Arrowhead Family Physicians (35)  Arthur-Menasch MD (36)  AseraCare Hospice (37)  Associates in Women's Health (38)  Asthma and Allergy Care Center (39)  Autism Model School, The (40)  Baldwin Wallace University (41)  Barnett, Robert M.D (42)  Baton Rouge Health Services (43)  Batton Rouge Senior Health Services (44)  Bay Park Family Practice (45)  Bay Park Hospital (46)  Bay Park Hospital Emergency Department (47)  Bay Park Internal Medicine (48)  Bay Park Women's Health (49)  Bay Park Women's Services (50)  Bayshore OB/GYN (51)  Bayside Women's Center (52)  Beach House, The (54)  Beach, Patricia (CNS-Pallative Care) (55)  Beasley, Gary R. DO (56)  Bedford Family Physicians (57)  Behavioral Connections of Wood County (58)  Bellevue City Schools (59)  Bellevue Hospital (60)  Bellevue Professional Services (61)  Bixby Hospital and Emergency Department (62)  Black, Marianne (63)  Blanchard Family Physicians (64)  Blanchard Valley Health System (Hem/Onc Internal Medicine) (65)  Blanchard Valley Health System: (66)  Blanchard Valley Hospital (67)  Blanchard Valley Medical Associates (68)  Blanchard Valley Medical Association (69)  Blanchard Valley Regional Health Center (70)  Blanchard Valley Surgical Specialists (71)  Blanchard Valley Women's Care (72)  Blissfield Family Care (73)  Bluffton Physicians, Inc. (74)  Bluffton Women's Care (75)  BMC&EMC (76)  Bodie, David MD (77)  Borgess Center for Diabetes Care (78)  Bowes, Robert (OB/GYN) (79)  Bowling Green City Schools (80)  Bowling Green Clinic (81)  Bowling Green Family Care Center (82)  Bowling Green Family Physicians (83)  Bowling Green Student Health Services (84)  Boyce, Vanessa K. (85)  Boys & Girls Club of Toledo (86)  Branch Hillsdale St. Joseph Community Health Agency (87)  Bronson Lakeview Family Care (Decatur, MI) (89)  Bronson Lakeview Family Care (Paw Paw, MI) (90)  Bryan City School District (91)  C & C Health Services (92)  Camp Courageous, Inc. (93)  CardioCare Consultants (94)  Cardiology Care Assoc.Inc. (95)  Cardiology Wellness of Toledo (96)  Caughman Clinic - BVRHC (97)  Caughman Health Center (98)  Center for Child Development (99)  Center for Family Health (Jackson, MI) (100)  Center for Family Health (Toledo, OH) (101)  Center for Health Services Medicine Clinic (102)  Center for Pulmonary Medicine (103)  Central Catholic High School (104)  Central Park Pediatrics (105)  Chartier Family Medicine (106)  CHCI (107)  Cherry Street Mission (108)  Childrens Hopsital Columbus (109)  Children's Hospital Medical Center of Akron (110)  Children's Intensive Caring (111)  Clark and Kasper Inc. (112)  Clark County Combined Health District (113)  Clay-Hufford, Susan, M.D. (114)  Cleveland Clinic (115)  Cleveland Clinic Foundation, The (116)  Cleveland Clinic Loraine Family Health Center (117)  Clyde Health Clinic, The (118)  Clyde-Green Springs Schools (119)  Cockley, Mark, MD Mark Cockley MD. LLC (120)  Columbus Regional Health Care System (121)  Community Care Clinic Cedar Creek Church (122)  Community Clinic at Baton Rouge, The (123)  Community Health Partners (124)  Community Health Services (125)  Community Health Services Fremont (126)  Community Hospice Care Tiffin (127)  Community Hospitals and Wellness Centers (128)  Community Memorial Hospital (129)  Community Mercy Health Partners (130)  Comprehensive Family Practice of Michael Neverauskas DO (131)  Confer-Seeley, Kim (133)  Corporation El Ayudante De Laboatories Divination Nicaragua American Central (134)  Country Creek Family Physicians Rochester Michigan (136)  Cuyahoga County Board of Health (137)  Danbury Local School District (138)  Darlington Nursing and Rehab Center (139)  Dasani, Suresh (140)  Defiance Clinic (Fauster-Cameron Inc. dba Defiance Clinic) (141)  Defiance County Health Department (142)  Defiance Family Practice (143)  Defiance Ortho Center (144)  Defiance Regional Hospital (145)  Defiance Regional Medical Center (146)  Delta Medical Center (147)  Dermatology Assoc. (148)  Dermatology Partners (149)  DeVries, Brent, D.O. (150)  Dialysis Partners of Northwest Ohio (151)  Diller, Jonathon, MD (152)  Diroff,Corinne, CNM Associates in OB/GYN (153)  Dood, Steven (154)  Doumet, Mahdi MD (155)  Drs. Detrick and Detrick (156)  Dundee Corporate Connection (157)  Dwight Schar College of Nursing and Health Sciences (158)  East Toledo Family Center (159)  Eastern Michigan University (160)  Elmore Medical Association Inc. (161)  Elmwood Local Schools (162)  Elyria City Health Department (163)  Elyria School District Board of Education (164)  Emergency Physicians of Northwest Ohio (165)  Endocrine and Diabetes Center (166)  Endocrine and Diabetes Center for Advanced Care (167)  Endocrine Specialists, PC (Monroe, MI) (168)  Endocrine Specialists, PC (Toledo, OH) (169)  ENT Physician's, Inc. (Oregon, OH) (170)  EPNO (172)  Erie County General Health District (173)  Erie County Health Department (174)  Erie County MRDD (175)  Erie West Hospice & Palliative Care (176)  Erwin, Kermit R., MD (177)  Evercare a United Health Group Clinic (178)  Executive Court Medical Associates (179)  Fairchild, Darleen M.D. (180)  Falcon Health Center (181)  Fallen Timbers Family Physicians (182)  Family Health Riverview Center (183)  Family House; Toledo Community Service Center (185)  Family Medical Associates (186)  Family Medical Associates of Findlay (187)  Family Medical Center of Michigan (188)  Family Medical Office (189)  Family Medicine Associates (190)  Family Physicians of Lima (191)  Family Practice Clinic Erie County Health Dept. (192)  Family Practice of Hillsdale (193)  Family Practice of Toledo (195)  Fauster-Cameron, Inc. dba Defiance Clinic (196)  Fay, Lorraine, MD (198)  Federman, Douglas (199)  Felix, Charles G., M.D. (200)  Figy, Rex Neil, M.D. Office of (201)  Fireland Physician Group Family Practice (SAHEC) (202)  Firelands Physician Group Urgent Care (Clyde, OH) (203)  Firelands Physician Group Urgent Care (Sandusky, OH) (204)  Firelands Physicians Group (205)  Firelands Regional Medical Center (206)  Fisher Titus Care (207)  Fisher Titus Medical Care LLC (East Milan, OH) (208)  Fisher Titus Medical Care LLC (Wakeman, OH) (209)  Flat Rock Physicians (210)  Flower Hospital (211)  Flower Hospital Family Residency (212)  Fondessy, Terrence MD (213)  Forrest, Todd DO (214)  Fort Hays State University (215)  Fort Meigs Family Physicians (216)  Fostoria City Schools (217)  Fostoria Community Hospitals (218)  Fostoria Family Medicine (219)  Foundation Park Care Center (220)  Franklin Park Pediatrics (221)  Fremont Board of Education (222)  Fremont Family Medicine (223)  Fremont Medical Center (224)  Fremont Medical Clinic (225)  Fremont Memorial Hospital (226)  Fremont Walk In Medical Center (227)  Ft. Meigs Family Physicians (228)  Ft. Meigs Perrysburg Family Practice (229)  Fulton County Health Center (230)  Fulton County Health Center Emergency Department (231)  Fulton County Health Department (232)  Gase, Andrew MD Family Practice Office (233)  Geauga County General Health District (235)  Geisler, John MD (236)  Gibbs, Terry MD (237)  Gibsonburg Exempted Village School District (238)  Girl Scouts of Western Ohio (240)  Gottfried, James Allen (241)  Gray, Wm. J. M.D. (Morence, MI) (242)  Gray, Wm. J. M.D., Inc. (Blissfield, MI) (243)  Graystone Family Practice (244)  Great Lakes Medical Services (245)  Great Lakes Urgent Care (246)  Grillis, Michael D.O. (247)  Gross, Thomas M.D. (248)  Gutowski, Scott R. (249)  H. C. Providers, LLC (250)  Hackl, Pamela DO (251)  Hagerman Family Physicians (252)  Hancock County Health Department (253)  Harbor Behavioral Healthcare (254)  Harbor Family Practice (255)  Harwani, Ashok N., M.D. (256)  Health Partners of Western Ohio (257)  Health Specialists of Lenawee, P.C. 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Answer If 7.9. Please select your third clinical location from the list below.  Please examine all options for your clinical  location before selecting your response.  If you don't s... CLINICAL LOCATION IS NOT IN LIST Is Selected Q7.9a 7.9a. Please provide the name of your third clinical location in the box below.

Q7.10 7.10. Please provide the following information about your third clinical location. Name of Unit/Department (2) Address (3) City (4) State (two letter abbreviation) (5) Zip Code (6) Phone Number of Clinical Location (XXX-XXX-XXXX) (7)

Q7.11 7.11. Is your third clinical location owned by a parent agency?  Yes (1)  No (2)

Answer If 7.12. Is your second clinical location owned by a parent agency? Yes Is Selected Q7.11a 7.11a. Please provide the name of the parent organization for your third clinical location. Name of Parent Organization (1) Address (2) City (3) State (two letter abbreviation) (4) Zip Code (5) Phone Number ((XXX-XXX-XXXX)) (6)

Q8.Txt SECTION VIII PREVIOUS PRECEPTOR OR CLINICAL MENTOR EXPERIENCE

Q8.1 8.1. Have you ever been a preceptor or clinical mentor of a nursing student?  No (1)  Yes (2)

Answer If Have you ever been a preceptor or clinical mentor of a nursing student? Yes Is Selected Q8.1a 8.1a. Please identify the type(s) of student(s) for whom you have been a preceptor or clinical mentor. Please select ALL THAT APPLY.  Associate Degree Nursing Student - Preceptor (3)  BSN Nursing Student - Preceptor (4)  MSN/APN Nursing Student - Preceptor (5)  DNP Nursing Student - Clinical Mentor (6)  PA Student (7)  Medical Student (8)  Other (please specify) (9) ______

Q8.2 8.2. Please briefly describe your competency in the area of clinical practice in which you will be a preceptor or clinical mentor.

Q9.Txt SECTION IX CONTACT PREFERENCES

Q9.1 9.1. At which of the following locations do you have access to the Internet? Please select all that apply.  Home computer (1)  Work computer (2)  Smart phone (3)  Tablet (4)  Other (please specify) (6) ______ Do not have Internet access (5)

Q9.2 9.2. Please provide your preferred e-mail address for receiving electronic communication from us. Please provide the e-mail address you use most often (daily or weekly). Preferred Contact E-mail (1)

Q9.3 9.3. Please provide the phone number we should use to contact you. Please provide the number at which we will be most likely to reach you. Preferred Contact Phone Number (XXX-XXX-XXXX) (1)

Q9.4 9.4. At times, it may be convenient to utilize a video teleconference call for you to discuss a student's progress with faculty. Which of the following tools do you prefer? Please select ALL THAT APPLY.  Face Time (1)  Google Play (2)  Hangouts (3)  OOVoo (4)  Skype (5)  Tango (6)  Viber (7)  We Chat (8)  Other (9) ______ You HAVE access to a device with video capabilities but have never used these capabilities. (10)  You DO NOT have access to a device with video capabilities. (11)

Q10.Txt SECTION X PRECEPTOR/CLINICAL MENTOR AGREEMENT

Q10.1 10.1. Please identify the nursing program(s) for which you have agreed to act as a Preceptor or Clinical Mentor by selecting the date range you will be you will be working with a student. Please select ALL THAT APPLY. Please scroll to the right ⇒ if you do not see all 4 selection columns on your viewer screen. Month you will BEGIN Year you will BEGIN Month you will End Y e ar y o u wi ll E N D M J J 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 M J J 2 A Oct A Oct Jan Feb M a u ul Au Sept Nov Dec 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Jan Feb M a u ul Au Sept Nov Dec 0 pr ob pr ob uar ruar ar y n y gu emb emb emb 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 5 uar ruar ar y n y gu emb emb emb 1 il er il er y y ch ( e ( st er er er 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 3 5 6 7 8 9 0 y y ch ( e ( st er er er 4 (4 (10 (4 (10 (1) (2) (3) 5 (6 7 (8) (9) (11) (12) (1 (2 (3 (4 (5 (6 (7 (8 (9 (1 (1 (1 (1 (1 (1 (1 (1 (1 (1 (2 (2 (2 (2 (2 (2 (2 (2 (2 (2 (3 (3 (3 (3 (3 (3 (3 (3 (1) (2) (3) 5 (6 7 (8) (9) (11) (12) (1 ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) 0) 1) 2) 3) 4) 5) 6) 7) 8) 9) 0) 1) 2) 3) 4) 5) 6) 7) 8) 9) 0) 1) 2) 3) 4) 5) 6) 7) ) ) ) ) Bacca laurea te                                                               (BSN) (1) Clinic al Nurse Leade                                                               r (CNL) (2) Family Nurse Practit                                                               ioner (FNP) (3) Pediat ric Nurse Practit                                                               ioner (PNP) (4) Doctor                                                               ate (DNP) Clinic al Mento r (5) (Table Truncated to 63 Columns)

Q10.2 10.2. Please provide the name(s) of the student(s) you will be precepting during the time you indicated in the prior question. Please provide the first and last name(s) of the student(s). First and Last Name of Student 1 (1) First and Last Name of Student 2 (2) First and Last Name of Student 3 (3)

Q10.3 Preceptor/Clinical Mentor Agreement Details and Signature Please read the following details about this agreement and type your name in the space below them as your electronic signature and agreement to act as a Preceptor or Clinical Mentor for the University of Toledo College of Nursing during the defined period of time selected above. I verify the accuracy of all information provided in this form and agree to act as a Preceptor or Clinical Mentor for students enrolled in the nursing program at the University of Toledo during the date range provided above. (1) I have a copy or have been directed to the on-line location of the Preceptor or Clinical Mentor Guidelines and have received and reviewed the course objectives for clinical experience of the student. (2) I understand that I will receive or be directed to an on-line resource location to obtain pertinent course materials from the course coordinator of students whom I have agreed to precept. (3) I understand I will receive student evaluation materials via e-mail from the College of Nursing and am required to complete and return these at midterm and at the end of the semester. Confidentiality All information obtained from you will be kept confidential and shared only with appropriate faculty and staff within the College of Nursing. Some information will be used by the College of Nursing in an aggregate format (by reporting only combined results and never reporting individual ones). Data will be used for accreditation, by regulatory bodies, and for improvement of the program. Questions about your role as a Preceptor or Clinical Mentor If you have questions please contact the College of Nursing at 419-383-5858 OR visit the College of Nursing website at http://www.utoledo.edu/nursing/faculty.html to obtain individual Program Director or faculty contact information. Please type your name in the box to the right to verify you have read the above Ohio Administrative Code (OAC) Rules (1)

Q10.Conc Please click on the "Submit" button in the lower right corner of this page to submit your completed form. You will not be able to change your responses once they are submitted. Shortly after your survey is submitted, you will receive an e-mail with a copy of your responses. Please print a copy of this e-mail for your records Thank you!

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Q10.Sig This section is for the program director to sign and date after reviewing the respondent's completed survey. Program Director Signature (1) Date (2)

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