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Preceptor Or Clinical Mentor Information Form - Copy 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.
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