College of Nursing Florida Atlantic University



Thank you for agreeing to precept an FAU Graduate Student. Please complete the following form. Detailed information for preceptors including information on tuition waivers is provided on the College of Nursing Website.Name of Facility:_______________________________________________________________Preceptor’s Name:________________________Office Address:_________________________City:________________Zip Code:_________Office Phone Number:______________________E-mail:__________________________Preferred Method of Contact: Phone e-mailCredentials : MD DO NP ? RN ? Other_____ Professional License #:_______________Highest degree held: Master’s DNP PhD MD DOState Issuing License:_________________Expiration Date:_____________________________National Certification(s) held: _____________________________ NPs: ANCC AANP MD or DO Specialty Certification:______________ Years of Experience in Specialty:________College or University Degrees and Dates Awarded:_________________________________________________________________________________________________________________This Section to be Completed by Student:I Agree to Precept (Student Name):____________________________________________Student’s FAU e-mail:_______________Student’s Phone:__________________________ Course Number and Name:___________________________________________________Semester: Fall Spring ? Summer Year:________Hours to be Completed:__________FAU Supervising Clinical Faculty Name:_______________________________________Faculty Contact Information Phone:__________________e-mail:____________________Preceptor’s Signature: Date:NP Program CoordinatorDr. Wisdom Chambers email kwisdom1@health.fau.edu Cell 561 543 9445 ................
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