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Detailed information for preceptors including information on tuition waivers is provided on the College of Nursing Website at  HYPERLINK "http://nursing.fau.edu/?main=4&nav=628" http://nursing.fau.edu/?main=4&nav=628 Preceptors Name:______________________________________________________________ Office Address:_______________________________________City______________________ State:_______________________Zip Code:________________ Office Phone Number:__________________________________E-mail:___________________ Preferred Method of Contact: ( Phone ( e-mail Credentials : ( MD ( DO ( NP ( PA RN Other_____ Professional License #:___________ Highest degree held: ( Masters ( DNP ( PhD (MD ( DO State Issuing License:_________________Expiration Date:_____________________________ National Certification(s) held: _____________________________ NPs: ( ANCC ( AANP MD or DO Specialty Certification:___________ All Preceptors: 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):______________________________________ Course Number and Name:_____________________________________________ Semester: ( Fall ( Spring Summer Year:________Hours to be Completed:_____ Clinical Faculty Cont2_i  9 : ; < E G T s ļtteVtGtGh Ih6CJOJQJaJh IhSTCJOJQJaJh IhYCJOJQJaJh IhKOCJOJQJaJh IhiCJOJQJaJ h IhSThSThSTCJOJQJaJjh_80JU h6IT0Jh_8jh_8Uh6ITCJOJQJaJh!hCJOJQJaJhKOCJOJQJaJhCJOJQJaJhSTCJOJQJaJ; < , . . 0 & ' | }  @ A d$Ifgd I   & * , . z     " $ . 0 L N V X ` b j ӵĵĦӛӍ~o]o]o]o" jh Ih5CJOJQJaJh Ih5CJOJQJaJh IhiCJOJQJaJ jh Ih6CJaJh Ih6CJaJh Ih!hCJOJQJaJh IhjCJOJQJaJh IhKOCJOJQJaJh Ih6CJOJQJaJh Ih_:_CJOJQJaJh IhcACJOJQJaJ#j l t         ! " & ' { | } вߣvdvvYh Ih6CJaJ" jh IhKOCJOJQJaJh IhjCJOJQJaJh IhSCJOJQJaJh IhSTCJOJQJaJh IhKOCJOJQJaJh IhiCJOJQJaJh Ih6CJOJQJaJh IhCJOJQJaJh Ihl;CJOJQJaJ" jh Ihl;CJOJQJaJ"    9 ? ] ^ p >źŠłŠrbrbrbrRrCh Ih;rCJOJQJaJh IhY5CJOJQJaJh IhFl5CJOJQJaJh IhS5CJOJQJaJh IhCJOJQJaJh IhYCJOJQJaJh IhKOCJOJQJaJh IhKOCJaJh IhSTCJaJh IhSCJOJQJaJh Ih6CJOJQJaJh Ih6CJaJ" jh IhKOCJOJQJaJ 8:6 7 `pkd$IfK$L$lt" t0644 lap yt Id$Ifgd IK$d$Ifgd I$d$Ifa$gd I >@BNZ46:NP\^ln 5 6 7 8 IJӲӣӔӋ|ufh IhcACJOJQJaJ h IhSh IhSCJOJQJaJ h IhYUh IhFlCJOJQJaJh IhjCJOJQJaJ" jh IhYCJOJQJaJh IhCJOJQJaJh IhYCJOJQJaJh Ih;rCJOJQJaJh Ihl;CJOJQJaJ"act Information:_____________________________________ Preceptors Signature:______________________________Date:___________________ _________________________________________________________________________ Program Director Lynne Palma DNP, FNP-BC, CDE Cell 954 815-0644 E-mail  HYPERLINK "mailto:Lpalma@fau.edu" Lpalma@fau.edu     CHRISTINE E. 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LYNNE COLLEGE OF NURSISNG           2 >D0    0' 42 P0 FLORIDA ATLANTIC UNIVERSITY         2 P0    0' 2 c 0 Preceptor  2 c^ 0 Credential/   2 c0 Agreement Form      2 c0    0'@"Calibri------  2 t`0    0'  2 `0  8  2 0  V /2 0 Approved 12/12 Masters   2  0 Committee   2 0    0'  2 `0    0'--- ,2 `0 Thank you for agreeing   2 0   42 0 to precept an ý Graduate    F2 '0 Student. Please complete the following       2 `0 form.   2 0 Detailed i  22 0 nformation for preceptors     I2 n)0 including information on tuition waivers         2 v 0 is provided  --- 2 ` 0 on the Colle  12 0 ge of Nursing Website at  --- D2 R&0 http://nursing.fau.edu/?main=4&nav=628  ---  2 P0  @ Calibri------- @ !R- Y---  2 `Y  --- 2 ` YPreceptor  2 Ys  2 Y  2 YName:_______   :2 Y_______________________________ /2 Y________________________  2 Y    2 `Y   S2 `0YOffice Address:_________________________________   ;2  Y______City______________________   2 Y    2 `Y   72 1`YState:_______________________  2 1:YZip   2 1NY   2 1WYC  2 1bYode  2 1yY:  2 1|Y______________ 2 1Y__  2 1Y    2 C`Y   D2 U`&YOffice Phone Number:__________________     #2 U~Y________________  2 UYE   2 UY-  2 U Ym  2 UYail  2 U)Y: (2 U-Y___________________  2 UY    2 h`Y  @"Calibri------ @ Calibri-----@Symbol------------------- +2 ~`YPreferred Method of C   2 ~Yontact:---  2 ~Y ---  2 ~!Y ---  2 ~,Y --- 2 ~1YPhone ---  2 ~]Y ---  2 ~hY ---  2 ~lYe  2 ~sY- 2 ~yYmail   2 ~Y    2 `Y  @Symbol---------  2 `YCredentials :  ---  2 Y ---  2 Y  2 YMD  ---  2 Y ---  2 Y  2 YDO ---  2  Y ---  2 Y  2 YNP ---  2 0Y ---  2 :Y  2 =YPA   2 VY?   2 bY  2 fYRN   2 Y?  2  YOther_____   2 Y  "2 YProfessional Li   2 <Ycense  2 ^Y  2 f Y#:___________  2 Y    2 `Y  --- +2 `YHighest degree held:  ---  2 Y ---  2 Y  2  YMasters ---  2 2Y ---  2 <Y  2 @YDNP ---  2 hY ---  2 rY  2 uYPhD  ---  2 Y --- 2 YMD  ---  2 Y ---  2 Y  2 YDO   2 Y    2 `Y   2 `TYState Issuing License:_________________Expiration Date:_____________________________         2 Y    2 `Y  ------------- 2 ` YNational  2  YCertification   2  Y(s) held:    2 %Y  82 )Y_____________________________   2 Y  2 YNPs:  2 7Y   2 @Y ---  2 DY ---  2 NY  2 RYANCC  2 Y ---  2 Y ---  2 Y ---  2 Y --- 2 YAANP  2 Y   2 Y    2 (`Y  @"Calibri--------- 2 :`YMD   72 :~Yor DO Specialty Certification      2 :7Y: 2 :: Y___________---  2 :Y    2 N`Y  --- #2 ``YAll Preceptors:   ;2 ` YYears of Experience in Specialty     2 `Y:_____  2 `Y    2 s`Y   52 `YCollege or University Degree     2 Ys  2 !Y  %2 'Yand Dates Awarded   ,2 Y:_____________________  2 OY______________  2 Y   |2 `KY___________________________________________________________________________  2 Y    2 `Y  V~@Times New Roman- - - - - -  2 ~VThis   2 *~VS  2 3 ~Vection to be   2 ~VC  2  ~Vompleted by    2 ~VS  2 ~Vtudent:  2 !~V    2 ~V  --- (2 ~VI Agree to Precept     2 ~V(  2 ~VS  2  ~Vtudent  2 1~V  2 8~VName)   D2 b&~V:_____________________________________  2 ~V_  2 ~V   2 ~V    2 ~V   &2 ~VCourse Number and    U2  1~VName:____________________________________________    2 ~V_  2 ~V    2 ~V  --- 2 , ~VSemester:  ---  2 ,~V ---  2 ,~V  2 ,~VFall ---  2 ,~V ---  2 ,~V  2 ,~VSpring   2 ,'~V   2 ,/~V?   2 ,;~V  2 ,?~VSummer    2 ,~~VYear  2 ,~V:__ %2 ,~V______Hours to be   2 ,,~V   2 ,0~VC   2 ,;~Vo 2 ,C~Vmpleted   2 ,s~V: 2 ,v~V_____  2 ,~V    2 ?~V   z2 QJ~VClinical Faculty Contact Information:_____________________________________        2 Q~V  '- @ !~-- @ !~-- @ !,-- @ !-- @ !-- @ !~-- @ !U~-- @ !U~-- @ !,U-- @ !-- @ !U-- @ !U----  2 d`Y  |ia 2 wh ai|Preceptors  e2 w<ai|Signature:______________________________Date:_______________    2 w}ai|____  2 wai|  '- @ !i`-- @ !i`-- @ !mia-- @ !i-- @ !i-- @ !j`-- @ !{`-- @ !{`-- @ !m{a-- @ !j-- @ !{-- @ !{---- w2 `HY________________________________________________________________________  2 Y_  2 Y   C2 %YProgram Director Lynne Palma DNP, FNP          2 Y- 2 YBC, CDE   2 BY   2 NY   2  YCell   2 #Y  2 *Y954 815  2 ^Y- 2 dY0644 2 Y   2 YE   2 Y- 2 Ymail   2 YLpalma@fau.edu     2 %Y @Times New Roman- - - - - - - @ !j-  '- @ !X-- @ !X-- @ !}Y-- @ !-- @ !-- @ !X-- @ !X-- @ !X-- @ !}Y-- @ !-- @ !-- @ !----  2 `0   "Systemv`)E|wv@vlw- -    00//..՜.+,D՜.+,, hp|   W  Title0 8@ _PID_HLINKSA Aimailto:Lpalma@fau.edu:('http://nursing.fau.edu/?main=4&nav=628  !"#$%&'()*+,-./023456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVXYZ[\]^aRoot Entry FXcData 1Table"WordDocument4,SummaryInformation(1KDocumentSummaryInformation8WCompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q