SON Home | UW Home | MyUW | UW Bothell | UW Tacoma | HealthLinks | Contact the School | Search SON | Internal


Faculty Support Home
Appointments, Promotion, and Tenure
School of Nursing Committees
Governance
Teaching
Student Advising
International Visiting Scholar
Research
Faculty Recruiting
Planning
School of Nursing Awards
Logistics
Safety

Preceptor Information Form
Precepting provides you with an opportunity to contribute to the quality of healthcare in our community through the mentoring of a new generation of healthcare providers.

Thank you for your interest in becoming, or continuing your tenure as, a preceptor for the University of Washington School of Nursing. Please fill out the form below to submit or update your information. If you do not have Javascript enabled on your computer, please fill out the MS Word version and fax, mail or e-mail the completed form to the address listed.


Personal Information
Name:
Job Title:
Credentials:
License No. (RN, MD, etc.):
Ethnicity:
SSN: (What's this for?)
Please call to give information

Contact Information
Agency:
Department:

Agency Mailing Address:


City: State: Zip:

Phone Numbers & Email:
Office:                 
Voice Mail:                 
Cell:                 
Pager:                 
Fax:                 

E-mail:

For placements, I would like information mailed to my home address.
No   Yes

Practice Information
I am available to precept during the following quarters:
Autumn   Winter   Spring   Summer

Work schedule/availability:

Do you accept first year graduate student placements?
No   Yes

Student level/experience preferred:

Common disorders or problems and patient age range seen in your practice:

Please indicate your specialties below:
(Hold down the Ctrl key to select more than one)


UW SoN Affiliation

Please indicate your UW School of Nursing department/focal area affiliation (if known):




If you encounter any problems using this form, please contact Jenn Hixson in Academic Services who maintains this page.
 
Copyright © 2008 University of Washington
1959 NE Pacific Street, Seattle, Washington 98195