ࡱ> _a^ bjbj 4b P888,j(<<<<oqqqqqq$Z! $"88<<000d88<<o0o00:p{<raQx [0)R$x${{$00$ :  Instructions for Preceptor Approval Process Student contacts willing preceptor. Student performs licensee search on the appropriate board website to verify license and 2) check for any disciplinary action or encumbrances. For Nurse Preceptors, go to:  HYPERLINK "https://www.ncsbn.org/license-verification.htm" https://www.ncsbn.org/license-verification.htm For non- nurse preceptors (MD, DO, PA, mental health professions), go to the appropriate website. For Missouri providers, go to:  HYPERLINK "http://pr.mo.gov/healingarts-public-information.asp" http://pr.mo.gov/healingarts-public-information.asp Student downloads a copy of the preceptors license verification information and the disciplinary report showing that license is free of encumbrances. Student types information on the preceptor information form to the extent that the information is known. Student verifies accuracy of information and obtains any missing information. This step is always necessary, even if the preceptor has taken SLU students in the past. Student submits preceptor form according to course guidelines. Course coordinator will review the preceptor information and give approval if the preceptor is appropriate for the course. Student verifies with clinical agency if an affiliation agreement is required or if proof of enrollment and SLUs Certificate of Liability insurance is sufficient. If affiliation agreement is required, student submits Facility Contract Request form to ksaunde4@slu.edu When the legal arrangement is negotiated, the course coordinator is notified. Course coordinator notifies student that the clinical site is approved. 鶹ý School of Nursing Preceptor Information Form Student Name Specialty Track (e.g. ACNP, FNP)Course Number Course CoordinatorSemester and YearPreceptor Contact InformationFull Name of PreceptorName of Clinical Site/Medical Group Street Address  Suite No., Department, Mail-Stop, Etc City, State, ZipOffice PhoneCell Phone (optional)FAX Number E-mail AddressOther contact informationBest Time & Preferred Method of ContactPreferred address for Verification of Precepting form (& thank you letter)Licensure/ Specialty Information*Send copies of license and other recognition documents. You must notify the School of any encumbrances or changes of status in your licensure or certification.Degree (s)License Type, State and Number Any current discipline to license? (Y or N)Specialty (e.g.Cardiology, FNP, LCSW) *If CNS or other please specify Subspecialty (if applicable)Certifying Body (e.g. ANCC, NCBPNP)Experience/studentsYrs experience: Current # of students:Clinical SettingClinical Setting Type (Hospital, Outpatient Clinic, please specify)Patient Population (e.g. Pediatric, etc.) Faculty to Fill OutDatesBeginning: Ending:Total Number of Clock Hours     Faculty Approval _____ Date _______ Entered into database ____ S  = > l m n u v 1 2 e f g h z 溬͎ͬͬ̀mm]mOhh5OJQJ^JhhI,0J5OJQJ^J$jhhI,5OJQJU^JhhI,5OJQJ^Jhh@5OJQJ^Jhh, 0J5OJQJ^Jhh, 5OJQJ^J$jhh, 5OJQJU^JhhN45OJQJ^Jh5OJQJ^Jhh>h5OJQJ^Jh 5OJQJ^J./Sn g h   Q p & Fxgdf & Fxgd x^gdN4 x^gd* x^gdI, & FxgdI, & Fxgd, & Fxgd & Fxgd $xa$gd z  i k {   P n p pǹ|n|^PhQ!h 5OJQJ^Jhfhf57OJQJ^Jhfh 5OJQJ^Jhfhf5OJQJ^Jhh@5OJQJ^JhLu5OJQJ^Jh5OJQJ^Jh 5OJQJ^JhLuh 5OJQJ^JhN4hN45OJQJ^JhhN45OJQJ^Jhh5OJQJ^Jhh 5OJQJ^J (pO}kd$$Ifl0$  t0644 layt@ $Ifgd L]Lgd $a$gd $xa$gd & Fxgd "D]aʹwwwwwb)h1h1B*CJOJQJ^JaJph hQ!h CJOJQJ^JaJ#h|Mh 5CJOJQJ^JaJh CJOJQJ^JaJ h|Mh CJOJQJ^JaJ hdh CJOJQJ^JaJh 5OJQJ^JhWh 5OJQJ^J8jh|Mh CJOJQJU^JaJmHnHtHux}kd$$Ifl0$  t0644 layt@ $Ifgd xx $Ifgd }kd$$Ifl0$  t0644 layt@"#xx $Ifgd }kd$$Ifl0$  t0644 layt@#$BCtt xx$Ifgd }kd $$Ifl0$  t0644 layt@CD[\{{$If}kd$$Ifl0$  t0644 layt@\]{{$If}kd0$$Ifl0$  t0644 layt@tnn$If $If^gd }kd$$Ifl0$  t0644 layt@tnn$If $If^gd }kd@$$Ifl0$  t0644 layt@tn$If $If^gd }kd$$Ifl0$  t0644 layt@xr$If $Ifgd }kdP$$Ifl0$  t0644 layt@{{$If}kd$$Ifl0$  t0644 layt@ {{$If}kd`$$Ifl0$  t0644 layt@  {{$If}kd$$Ifl0$  t0644 layt@56{{$If}kdp$$Ifl0$  t0644 layt@67_`{{$If}kd$$Ifl0$  t0644 layt@`a{{$If}kd$$Ifl0$  t0644 layt@p~/02FǵpbQIEIEIEIEhtsjhtsU hh CJOJQJ^JaJh CJOJQJ^JaJ hhw_^CJOJQJ^JaJ hh CJOJQJ^JaJ h|Mh CJOJQJ^JaJ#hQ!h 5CJOJQJ^JaJ#h|Mh 5CJOJQJ^JaJ h|Mh1CJOJQJ^JaJ)h1h1B*CJOJQJ^JaJph#hLuB*CJOJQJ^JaJphptt xx$Ifgd }kd $$Ifl0$  t0644 layt@pq|}{{$If}kd $$Ifl0$  t0644 layt@}~{{{$If}kd $$Ifl0$  t0644 layt@{{$If}kd $$Ifl0$  t0644 layt@{{$If}kd( $$Ifl0$  t0644 layt@89{{$If}kd $$Ifl0$  t0644 layt@9:^_{{$If}kd8 $$Ifl0$  t0644 layt@_`t{{$If}kd $$Ifl0$  t0644 layt@tn$If xx$Ifgd }kdH $$Ifl0$  t0644 layt@{{$If}kd $$Ifl0$  t0644 layt@/01{{{$If}kdX$$Ifl0$  t0644 layt@12FGtn$If xx$Ifgd }kd$$Ifl0$  t0644 layt@GHNu{{$If}kdh$$Ifl0$  t0644 layt@uv{{$If}kd$$Ifl0$  t0644 layt@|zzzzzzzzjz$ ]a$gd gd }kdx$$Ifl0$  t0644 layt@ Ͼݺݺ hh CJOJQJ^JaJ hX h hts hYh CJOJQJ^JaJh CJOJQJ^JaJh hXh CJOJQJ^JaJh CJOJQJ^JaJ gd $a$gd 21h:p / =!"#$% $$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@$$If!vh#v#v :V l t0655 yt@b 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~PJ_HmH nH sH tH D`D NormalCJ_HaJmH nHsH tHDA D Default Paragraph FontRi@R  Table Normal4 l4a (k (No List jj  Table Grid7:V04@4 YHeader  !4 @4 YFooter  !H@"H  ? Balloon TextCJOJQJ^JaJ6U`16 , Hyperlink >*B*phPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK]   b 33OOORz  / #C\ 6`p}9_1Gu  !"#$%&'()*+,-.0=l1e XX@ @H 0(  (  z @ # s"*?? B S  ? Et SSfpzx{OP 93T^Tcr:»^`7o(. ^`hH. pL^p`LhH. @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PL^P`LhH.8^8`o() ^`hH.  L^ `LhH.  ^ `hH. x^x`hH. HL^H`LhH. ^`hH. ^`hH. L^`LhH.93T93T crPle Qiti/ Se.MTmalU styWme:Xe NѰ                 e -,@qI, /0t'qo)H+rK+z/ 3"7j: @TwBD4LTMw_^/ay^kdlfmw, S$N?7`1N4LuO9 )>hp*? stsJR @ @UnknownG*Ax Times New Roman5Symbol3. *Cx Arial;|i0Batang5. .[`)TahomaA$BCambria Math"qhm'm'#Ɇ  !24 .3QHP ?2!xx (Saint Louis University School of NursinglachhOwner  Oh+'0h   $ 0 <HPX`,鶹ý School of NursinglachhNormalOwner2Microsoft Office Word@V@ S@IQ@IQ ՜.+,D՜.+,h$ hp  鶹ý  )鶹ý School of Nursing Title| 8@ _PID_HLINKSA4 'q4http://pr.mo.gov/healingarts-public-information.aspn/https://www.ncsbn.org/license-verification.htm  !"#$%&'()*+,-./013456789:<=>?@ABCDEFGHIJKLMOPQRSTUWXYZ[\]`Root Entry F aQbData 21Table;$WordDocument4bSummaryInformation(NDocumentSummaryInformation8VCompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q