Become a Preceptor

1

Provider Information

Tell us about yourself and your practice.

First Name*

Last Name*

Email*

Phone

Practice Name

NPI Number

Practice Street Address*

City*

State*

Zip Code*

Practice Setting Description

Office / Admin Contact (if different from provider)

Admin Contact Email

Admin Contact Phone

2

Patient Population

Approximately what percentage of your patients fall into each age group?

Infants (0-1 yr)

Children (2-12 yr)

Adolescents (13-17 yr)

Adults (18+ yr)

On average, how many patients do you see per day?

3

Precepting Experience

Tell us about your experience precepting students.

4

Availability

When are you available to precept students?

5

Student Fit

Help us match you with the right students.

Preferred student level*

Beginner (first clinical rotation)Intermediate (has some clinical hours)Advanced (final rotations)Any level

Skills or qualities you value in a student

What makes an ideal student for your practice?

6

Telehealth

Let us know about your telehealth practice, if applicable.

Do you offer telehealth services?*

Yes

No

7

Honorarium / Compensation

What is your preference for precepting compensation?

Compensation preference*

Volunteer (no compensation)

I am willing to precept on a volunteer basis with no financial compensation.

Flat Fee (Per Rotation)

I would like a flat fee for the entire clinical rotation.

Per Credit Hour Required

I would like to be compensated per credit hour required by the student's program.

8

Administrative Preferences

How would you like us to communicate with you?

Preferred communication methods*

EmailPhoneText / SMSVideo Call

Preferred Email

If different from above

Preferred Phone

If different from above

9

License & Acknowledgments

Provide your license number and confirm the statements below to complete your application.

License Number*

Secondary License Number

If applicable (specialty or dual license)

CV / Resume*

Most nursing programs require a preceptor CV or resume to approve clinical placements. Uploading this document allows us to verify credentials and expedite placement approval once a match is identified.

Click to upload

PDF, DOC, DOCX up to 10MB

Copy of License*

Please upload a copy of your current professional license. This helps us verify your credentials and expedite the approval process.

Click to upload

PDF, JPG, PNG, DOC, DOCX up to 10MB

Acknowledgments *

Please read and confirm each statement below.

I am genuinely interested in precepting nurse practitioner students and understand this role involves mentoring, teaching, and supervising clinical experiences.I understand that submitting this form does not guarantee a student placement, and that placements are subject to mutual agreement and availability.I understand that my relationship with the student is professional and educational, and I agree to maintain appropriate boundaries.I certify that the information provided in this application is accurate and complete to the best of my knowledge.

Provider Information

Patient Population

Precepting Experience

Availability

Student Fit

Telehealth

Honorarium / Compensation

Administrative Preferences

License & Acknowledgments

What Happens After You Submit