Preceptor Profile

I Have Precepted a CSB Graduate Student in the past:

	Yes
	No

If you answered YES to the question above and have already submitted the form or a C.V., you do not need to complete the form below. If you are a new preceptor to CSB, please complete the form below or email a copy of your C.V to [email protected]

Preceptor:

	Name and Credentials
	License Number and Expiration Date
	Specialization Area
	Years of Experience
	Current Employer
	EMail Address
	Phone Number

Education: List your basic medical /nursing education/advanced education as a physician or in nursing or other fields.

	Name of College
	Location
	Degree Earned
	Dates of Attendance

Certification: List any certifications you hold.

	Name of Certification
	Certification Organization
	Dates of Certification

Clinical Experience: List your most recent clinical experience other than your present employment

	Name of Employer
	Job Title/Responsibilities
	Dates of Employment

Professional Honors and Awards: List any special professional honors/awards you have received.

Preceptor Experience: List prior preceptor experience with CSB, other colleges, hospitals, and health care organizations.

	Name of Organization
	Type of Student
	Dates/Length of Preceptorship

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