Preceptor and Facility Agreement

Please use appropriate capitalization when completing this form.  It is extremely important to use the preceptor's proper name (no nicknames) and proofread the entire form prior to submitting. This information will be sent directly to your preceptor. Please note that any inaccuracies/errors will cause a delay in processing your request.
 
FOR MSN EDUCATION STUDENTS: You must have approval from your course faculty before completing this form. 
Student IDs begin with 5000xxxxxx or 6000xxxxxx
Some older Student IDs have the format xxx-xxxxxx.
 
(Use Patriot's Email)
(Use Patriot's Email)
PLEASE make sure you select the correct faculty member. 
 
FNP: 
NURS 5351- PC 1: Dr. Marcie Lusk
NURS 5353- PC 2: Dr. Angie McInnis
NURS 5455- PC 3: Dr. Tanya Schlemmer
Practicum 1: Dr. Amy Roberts
Practicum 2: Dr. Andrea Oliver
 
MSN Admin: please check your schedule
MSN Educ: Nurs 5329
Please make sure to select your correct faculty member, as a copy of this agreement is sent directly to your instructor for approval.
 
 
 

Preceptor Information

Please enter Preceptor Name as it appears on the license.
Is this Preceptor listed in Typhon? *
Gender: *
calendar
Certifying Board Name: *
 

Facility Information

If the facility is already on the approved list, please list it as it appears there.  Also, please do not abbreviate names.
Is this Facility affiliated with another organization or covered under a corporate umbrella? If yes, which one? *
 
Is this facility already on the approved list? *
The Contact person IS NOT the preceptor! The Contact person is the representative at the facility who is financially responsible for signing contracts.
MSN Education students: The contact person for your agreement is the Dean/Chair of the School of Nursing.
Type of Facility: *
Please select the classification of this facility (most commonly used): *
 

A copy of the agreement will be sent to you and to the preceptor at the addresses you provided.

Clinical Coordinator: La Keitha Johnson, LaKeithaJohnson@uttyler.edu