Preceptor Program at the Frances Payne Bolton School of Nursing

PRECEPTORS

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