Preceptor Information Form (FNP)

Troy University

Preceptor Information Form (FNP)

Revised 11/3/14

Students: Please complete entirely and return to your instructor. This form will not be processed if not complete. Type in information. Submit as a Word document attached to an email to your clinical faculty*.

Course Number: NSG 6613 Advanced Health Assessment Preceptorship

(Check one) NSG 6666 Primary Care I Preceptorship

NSG 6668 Primary Care II Preceptorship

NSG 6680 FNP Internship

Semester/Year: Fall ______Spring ______Summer

Student Name: First name Last Name email address

Phone: Work ( ) __ Home ( ) Cell ( ) ______

Agency Name:

Address:

City, State, Zip:

Do you have an RN license in preceptor’s state? _____ Have you updated documents in Typhon? _____

Contact Person: @

First name Last Name email address

Title: Phone: __

Preceptor: @

First name Last Name email address

Title: Phone:

(MD, NP, PA)

Preceptor Unit:

Faculty: Approval:

* Clinical Faculty:

Mtg- Dr. Farrell/ Dr. Burns PC- Dr. Whitted Troy- Dr. Jones Dothan- Dr. Mason

Office Use Only
Received:
Letter Sent:
Agency Agreement Received: