Forms Manager

Preceptor Agreement Form

Date:

Preceptor Name and Credentials

Preceptor Clinic Name/Agency

Student Name

Course Number

Semester:

	Fall
	Spring
	Summer

College of St. Benedict
DNP-Family Nurse Practitioner Program

Confirmation of Agreement to Precept

I have met with the graduate student or faculty regarding a preceptorship at this agency. I have reviewed the preceptorship agreement, and we have discussed the course objectives, clinical requirements, and the FNP student evaluation document for the course number indicated above and agree to act as a clinical preceptor to the student named above as part of his/her enrollment in the CSB graduate nursing program clinical course. I am aware that I will need to confer with the Clinical Instructor during and at the end of the semester to provide any information I believe is necessary regarding the student’s progress in the clinical practicum. A written evaluation of the student, on the provided form should be submitted at the end of the semester. I meet the following minimum qualification to precept this student:
• Possession of current Minnesota license to practice as a nurse practitioner, physician, physician assistant, or certified nurse midwife.
• A copy of my MN license to practice is available at my facility
• At least one year of clinical experiences as a physician, physician assistant, nurse practitioner or certified nurse midwife in primary care or specialty care area
• In a group practice, any other provider participating in the supervision of the student must also meet the same qualifications with regard to education and clinical experience.

I am willing to serve and be available as a preceptor for this student enrolled in the above named course during the period of the semester indicated above.

I am also aware that I must complete the FNP student evaluation document prior to the end of the semester for which the student is enrolled.

I agree to the terms set forth above.

Signature - Electronic typed name is accepted as a signature.