School of Nursing - LSU Health New Orleans

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Graduate Preceptor Credentialing

*First Name:  
  *Last Name:  
*Certification Type: (i.e. M.D.,FNP,CNS,CNM)  
*Name of Certifying Board:
*College or University:
*Date Completed:
*Clinical Facility Name:
Mailing Address :
  State:   Zip:  
*Phone Number w/Area Code:    
*Population Focus:  
*Years of Practice in Area:
*Number of students precepting concurrently:  

I, * (preceptor's name), agree to act as preceptor for a Nursing Graduate Student at LSUHSC, School of Nursing and assist the student to achieve the course outcomes for the course.

I have been provided a copy of the preceptor graduate orientation handbook.
I understand I will be responsible and accept the responsibilities outlined in the preceptor orientation handbook.
I verify accuracy of all information and have received and reviewed the course outcomes for this student.
I have attached a copy of a current CV/resume.

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