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DNP Clinical Site Form

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Preceptor's name and credential's
You must also send the preceptor's CV to Pam Moore.

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Is the preceptor board certified?

 Yes
 No
 

Best time to contact preceptor?

Does the preceptor want access to your clinical logs?

 Yes
 No

Practice/Group Information

Please provide the full legal name of the Practice/Group facility below.

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Is facility affiliated with one main facility? (example: Carilion Clinic)

 Yes
 No

If yes, name of facility

Does facility accept Radford University contract or have their own?

 Yes
 No

Does the facility require any specific forms or training from student?

 Yes
 No

If yes, list forms and training required

Estimated date that you plan to start clinicals at this site

General questions and information

  1. Who is responsible for signatures on the contracts? This may be the provider, facility, or both.
  2. Who approves the possible clinical site? First, the student locates a facility and arranges a preceptor. Then the student notifies his or her course faculty who must approve the site. Then, Pam Moore needs all practice information to set up a contract. You cannot start clinical until Pam has received all contracts and notifies you that you may begin.
  3. What other information is required? A CV from the preceptor and a picture if possible. This may be sent to Pam Moore or mailed to the Radford University School of Nursing, PO Box 6964, Radford, Virginia 24142.
  4. Contract will be sent from and returned to Pam Moore, Radford School of Nursing, PO Box 6964, Radford, Virginia 24142.
  5. Preceptor may request and have access to the student's Typhon clinical log. The course faculity will need to contact the preceptor during the semester so he/she needs to contact information (phone, email) from the preceptor.
  6. Laura LaRue, FNP coordinator, is available to help with any concerns.
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Not subject of a workflow