Scan and completed forms to

Transcription

1 FAMILY NURSE PRACTITIONER *** Clinical Placement Planning Forms*** For office use only: New Continuing The packet consists of 5 pages. Students are responsible for completion of these forms. Only completed forms will be accepted. Contracts must be in place by th e first day of class. NOTE: YOUR PRECEPTOR SHOULD ONLY BE ASKED TO REVIEW and SIGN forms. (Preceptors should provide a CV or Resume if not previously established with GSW School of Nursing.) Scan and completed forms to tiffany.kitchens@gsw.edu. PART A STUDENT INFORMATION Student Name Complete Permanent Address (Street or PO Box) Contact Information with area codes: Cell Phone Home Phone Personal or Other contact information GSW Address Work phone (print if handwritten) Current RN licensure: State(s) #(s) date CastleBranch Background Check, Drug Test, Tracker status: (mark all that apply) purchased renewed/updated immunizations current TB test flu shot liability insurance current If incomplete, state reason COURSE INFORMATION Please mark Course Number: NURS 6225 NURS 6226 NURS 6227 NURS 6228 NURS 6229 NURS 6425 Term & Year: SPRING 20_ FALL 20 SUMMER 20_ FNP Student Signature (Date) Page 1 of 5

2 PART B PRECEPTOR INFORMATION (Must be completed in full. All information is confidential) For office use only: Established New CV/resume Student Name: Preceptor Name: Please mark your status as a preceptor for GSW School of Nursing: NEW (Please attach CV or Resume ) Established Credentials (mark one): NP PA_ DO MD CNS CRNM Other License Number State Date Certification Agency Years in current role address: Best phone number to contact Date This address will be used for I agree to serve as preceptor for the student requesting my supervision: Preceptor s Signature If your state requires collaboration for your preceptor, enter the name of the: Collaborating Physician his/her Certification date Certifying Agency Specialty of Physician Preceptor (mark the most accurate): Cardiology Geriatrics Neonatology Obstetrics Women s Health Emergency Medicine Gynecology Neurology Pediatrics Family Practice Internal Medicine Oncology Surgery Other (provide specialty) Specialty of Nurse Practitioner (mark the most accurate): Adult Acute Adult Primary Family Geriatrics Medical Surgical Midwifery Neonatal Peds Acute Peds Primary Women s Health Occupational Health Oncology Other: Page 2 of 5

3 PART C PRECEPTOR S PRACTICE INFORMATION (Must be completed in full) Established preceptor New Preceptor Student Name Clinic/Agency Preceptor s Information Clinic/Agency Name: Clinic/Agency Street Address: (clinic location number and street) Office Manager: Address Telephone with area code (print if handwritten) Fax Number Mark Correct Description of Agency: Rural Clinic Academic Medical Center Clinic Inner City Clinic Public Health Department Clinic Specialty Clinic Private Practice Other Clinic/Agency Mailing Address (if different from street address): The Legal Name of the clinic, group or physician who owns the practice: (Note: Legal name and clinic name may or may not be the same) Person Legally Authorized to Sign Contracts: Name Fax (print) Page 3 of 5

4 PART D CONTRACT WITH GSW & CLINICAL SITE This clinical site has an existing MOU with GSW under the name of: Existing MOU Semester Contract expiration date. If no MOU exists, please fill out the following Semester Contract Agreement. This form will serve as a Semester Contract Agreement between: Clinical site name City state zip and the School of Nursing at the Georgia Southwestern State University, Americus, Georgia when appropriate signatures have been affixed below by Dr. Sandra Daniel, Dean of the School of Nursing, and the authorized agency representative for the clinical site. The agreement will grant permission to, Student name a student enrolled in the Family Nurse Practitioner program at GSW to obtain part of his/her clinical experience through this facility. The student will work with Preceptor name and title as preceptor. The term of the agreement will be: Spring semester: January 1, through April 30, Summer semester: May 1, through July 31, Fall semester: August 1, through December 15, If the terms of this agreement are acceptable to you and your agency, please sign below and keep a copy for your records. SIGNATURE of Person Legally Authorized to Sign Contracts Date Sandra D. Daniel, PhD, RN Dean and Professor, School of Nursing Page 4 of 5

5 PART E AFFILIATED HOSPITAL INFORMATION Existing Semester MOU_ Contract Complete this form only if you will be doing your clinical rotation with patients in the hospital in collaboration with your preceptor. Hospital Information: Legal Name of Hospital (This must be the hospital affiliated with preceptor for the specified term) Projected Effective Date of Contract (Beginning of specified term) Chief Nursing Administrator or Education Coordinator with title: FAX Person Legally Authorized to Sign Contracts: Name with title FAX (print) Page 5 of 5