Preceptor Pre-Application Submission
School Nurse Intern’s Name:
Semester:
PRECEPTOR’S INFORMATION
Name (
Required
):
Credentials:
BSN
MS
NP
DnSC
PhD
SN Certification Year:
Program:
Certifications:
Home Address:
Home Phone (
Required
):
(xxx-xxx-xxxx)
Work Phone (
Required
):
(xxx-xxx-xxxx)
Home E-Mail:
Work E-Mail (
Required
):
School Dist. Name & No.:
School Dist. Address:
City, State, Zip:
School District County:
Are you employed full time?
Yes
No
Professional Memberships:
Special Projects/Passions:
Preceptor/Mentoring Experience:
Yes
No
If Yes, see below:
Year
:
Program
:
Student's Name
:
College of Nursing
School Nursing Program Department of Public Health
Mental Health, and Administrative Nursing (MC 802)
845 S. Damen Avenue
Chicago, Illinois 60612-7350 312.996.4543