CLINICAL PRACTICUM EXPERIENCE AGREEMENT
This form should be completed by the student,shared with the preceptor, signed by both and returned to Course Faculty no later than the first clinical day. Students must have a signed preceptor agreement form for any clinical practice in which they interact in a student practitioner role with patients and provide supervised direct patient care. Strictly observational experiences do not require an agreement.
Regis University, Loretto Heights School of Nursing and ______
(preceptor’s name, credentials)
of ______agree to provide an independent precepted
(agency/facility)
practicum experience for ______in
(student’s name)
______
(course number and name)
It is understood that the student will be in the agency for approximately ______hours
to be scheduled between the dates of ______to ______.
Each student is expected to communicate course and individual specific learning objectives with the preceptor while under their direct supervision. Each student is expected to abide by the policies and procedures of the agency/facility, function in the role of a student within the parameters of the course objectives, arrange their schedule, and communicate information to the preceptor and course or clinical faculty during the experience.
The preceptor’s role with the student is one of teaching and supervision to enable the student to achieve both her/his personal stated objectives and the course objectives. The preceptor agrees to provide clinical supervision while allowing the student to participate in providing supervised direct/indirect patient care. In addition, the preceptor has responsibility for the student’s actions while under supervision and assures that the student’s performance conforms to professional standards of practice. The preceptor has the right to limit the student’s activities for any reason includingunprofessional behavior or belief the student is acting in an incompetent or unsafe manner. In such an instance, the preceptor is expected to directly contact the course or clinical supervising faculty member.
Preceptor responsibilities,in addition to those of supervision,include but are not limited to acting as a resource person for the student, facilitating learning experiences while the student is in the agency, communicating with course or clinical faculty as appropriate, and contributing a written evaluation of the student’s performance in accordance with the course description and objectives.
______
Print Preceptor Name
______Date: ______
Preceptor’s signature
______
Print Student Name
______Date: ______
Student’s signature
______
Print Course Faculty Name
______Date: ______
Course Faculty
Regis University - Loretto Heights School of Nursing
Insert a copy of your Preceptor’s resume or brief professional biographyhere
Student: Upload or scan this document into an electronicformat that is to be placed into the NR478R Community Health CourseDropboxby the end of Week 1,and send a copy via this e-mail link to the administrative assistant for your student file.
1
2013