Academic Programs > Preceptor Program > Forms

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Preceptorship Forms

Clinical Preceptor Hours Verification


Name of Preceptor:

Semester:
Year
Course No:

Name of Student:

Specialty/Practice:

Practice Site:

Phone Number of Preceptor:

Certifying Organization:

Total Number of Hours Completed with This Student:

Please PRINT the completed form and fax to Sandra Jorgensen at 216-368-3542.

Sandra Jorgensen
Preceptor Coordinator
Frances Payne Bolton School of Nursing
216-368-3198
FAX: 216-368-3542
Office: 304B