Student Preceptor Form and Documentation

Preceptor Form and Documentation

American Sentinel College would like to thank you for agreeing to be a preceptor for our nursing student. Your commitment to this process demonstrates your personal dedication to the continuing development of nurses. For questions, please email, asc-practicum@post.edu
STUDENTS: You should only be filling out this form if this is your first time requesting a preceptor.

PRECEPTORS: Please select "next" at the bottom of this form so you can progress to the appropriate page.
Student Information (If you are a preceptor, please click "next" at the bottom of this page)
First Name
Last Name Name
Email Address
example@example.com
Program
Preceptor Name

First NameLast Name
Preceptor E-mail
example@example.com
By Signing this form you agree that your preceptor has agreed to act as your preceptor, and that they have the required qualifications.

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Preceptor Information: This page is for the preceptor to complete.
Preceptor Full Name
First Last
Preceptor's Email Address
Highest Degree Earned
American Sentinel Student Name
First Last
American Sentinel Student Email
example@example.com
American Sentinel Student Specialization
PE Facility Information

The student will confirm if an affiliation agreement with American Sentinel University is required to complete precepted practice experiences at this site.
Facility Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Relevant Documents

Please upload the following documents. A copy of your current resume/CV and current RN license will be stored for compliance reasons only and will not be shared.
Current CV or resume

Upload a File

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Proof of current RN License

Upload a File

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Please review the Preceptor Orientation Packet before submitting this form.
At the completion of the precepted practice experience, you will need to upload the evaluation form. Each preceptor contributes to the evaluation of the student’s performance during the precepted practice experience. The faculty of record/Practicum Coordinator, with input from the preceptor, is responsible for assigning a pass/fail designation for the precepted practice experience. Click here for the evaluation, and save the link. You will be required to submit this document at the end of the precepted hours.
By signing this form I acknowledge that I have read and understood the Preceptor Orientation Packet.

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Practicum Email
example@example.com

For reviewer only
Preceptor Name

First NameLast Name
Student E-mail
example@example.com
American Sentinel Student Name

First NameLast Name
The preceptor has:

Met the minimum qualifications to be student's preceptor. .Has NOT met the minimum qualifications to be student's preceptor.
Comments if preceptor is denied:
Practicum Coordinator Signature

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Should be Empty:

Preceptor Form and Documentation

For reviewer only