Pdf georgia board of nursing valdosta edu

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GEORGIA BOARD OF NURSING PRECEPTOR QUALIFICATION RECORD

Name

Georgia License

Last

First

Maiden/Middle

Cert. type & number

Address

Street

Cert. Exp. Date

City

State

Work Phone

Home Phone

Email

Employed by

Agency/Institution

Address

Clinical Area of Expertise List professional education/National certification in chronological order:

Length of time in this agency (must be a minimum of one year)

# #______________ _________ ___________ Zip Code

Name of Institution

Location

Diploma/Degree National Cert.

Year Granted

Major Field

Date of first licensure

Work History to develop this area of expertise.

POSITION

AGENCY/Location

DATES

Preceptorship: Name of affiliating nursing education program Valdosta State University College of Nursing

Please describe how the student's learning goals are/will be enabled by your education and/or expertise:

My signature (preceptor) below indicates my willingness to serve as a preceptor for the following courses:

I have received a copy of the preceptor responsibilities and the course objectives. I understand the faculty member will provide me with student name(s), telephone number(s) and dates of student clinical experiences in writing. The faculty will also provide me with telephone numbers of faculty involved in the above courses. The agency/designee signature indicates acknowledgment and approval of the preceptor position for this employee.

PRECEPTOR SIGNATURE

AGENCY/DESIGNEE SIGNATURE

DATE

DATE

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