Get Qualified Preceptor/mentor Summary Form

The QUALIFIED PRECEPTOR/MENTOR SUMMARY FORM is an essential document that facilitates the mentoring relationship between students and their preceptors. This guide will provide you with clear, step-by-step instructions to ensure you complete the form accurately and effectively.

Follow the steps to fill out the QUALIFIED PRECEPTOR/MENTOR SUMMARY FORM online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the student's name in the 'Student Name' field.
3. Input the student's identification number in the 'Student ID#' field.
4. Specify the 'Program of Study/Degree' the student is enrolled in.
5. Fill in the 'Site Name' where the practicum or clinical will take place.
6. Provide the site address by entering details in 'Address 1' and 'Address 2' fields, followed by the 'City', 'State', and 'Zip' code.
7. Enter the preceptor’s or mentor’s name in the 'Preceptor’s/Mentor’s Name' field.
8. State the title of the preceptor or mentor in the designated field.
9. Input the preceptor’s or mentor’s phone number.
10. Provide the email address of the preceptor or mentor.
11. Enter the preceptor’s or mentor’s credentials in the appropriate field.
12. Indicate the number of years of experience the preceptor or mentor has in the field.
13. Select the appropriate response to the question about supervising students in the past (Yes or No).
14. If applicable, state how many semesters the preceptor has supervised students.
15. Fill in the education section with the institution and division/school the preceptor attended.
16. Indicate the major and the highest degree earned by the preceptor.
17. Provide the year of graduation of the preceptor.
18. Attach a copy of the most recent license or certification if it is relevant.
19. The preceptor or mentor should sign the form in the 'Preceptor’s/Mentor’s Signature' section.
20. Finally, enter the date of completion for the form.
21. Once you have filled out all necessary sections, save your changes, and choose to download, print, or share the completed form.

Complete the QUALIFIED PRECEPTOR/MENTOR SUMMARY FORM online today.