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FNP Masters Program
PRECEPTOR PROFILE SHEET
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Instructions:
<TAB> between fields. DO NOT USE THE <ENTER> KEY until ready to
submit. In Option fields, use the <Arrow> keys to move between
selections. |
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NAME |
First Name
Last name
Name of Your
Facility
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ADDRESS -
Physical Address of your facility: |
Street
City
State
ZIP
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ADDRESS - Mailing
Address of your facility (if different from above): |
Street/Box
City
State
ZIP
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PHONE & EMAIL
type
w/o dashes (example:1234567890) |
Facility Phone
Number:
Facility Fax Number
Facility or
preceptor e-mail address:
How would you prefer
to be contacted by the FNP faculty? (choose one)
Phone
Fax
Mail
E-Mail
If you would like to
be contacted at an address or phone #
that is different from
what you provided above, please list it here:
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OTHER POTENTIAL
PRECEPTORS |
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Please list the names,
degrees, phone numbers and e-mail addresses of any other
potential preceptors at your site or other providers that
frequently help you with FNP students: |
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Potential
Preceptor #1: |
Name:
Degrees:
Phone #:
E-mail Address:
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Potential
Preceptor #2: |
Name:
Degrees:
Phone #:
E-mail Address:
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Potential
Preceptor #3: |
Name:
Degrees:
Phone #:
E-mail Address:
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Potential
Preceptor #4: |
Name:
Degrees:
Phone #:
E-mail Address:
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Getting to You |
If your facility is
often described as "hard to find," please
provide directions and/or a physical description of your
facility:
Please provide any
special parking instructions
for FNP students and/or UW FNP
instructors:
If you are in a
remote location where
students typically have to spend the night,
what recommendations do you have regarding lodging?
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Meals: |
Do FNP students have
access to a refrigerator at your facility?
Yes
No
Do FNP students have
access to a microwave at your facility?
Yes
No
Are there vending
machines located near or in your facility?
Yes
No
If "yes" to vending
machines, please list the
types of machines (i.e., soda, juice,
chips, etc.):
Are there eating
facilities located near your facility?
Yes
No
Do you expect
students to exit the facility during meal-time closures?
Yes
No |
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Preferred student
hours: |
On what days of the
week is your facility typically open?
What hours is your
facility typically open?
What days and hours
can you typically accommodate FNP students?
What time do you
expect students to arrive at your facility each day?
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Time-wise, how often
do you prefer to precept FNP students? (Important field!
Please check some option!)
one
half-day/week [check preferred days]:
Su,M,
T,
W,
Th,
F,
Sa
multiple
half-days/week [check preferred days]:
Su,M,
T,
W,
Th,
F,
Sa
one
day/week [check preferred days]:
Su,M,
T,
W,
Th,
F,
Sa
two
days/week [check preferred days]:
Su,M,
T,
W,
Th,
F,
Sa
three
days/week [check preferred days]:
Su,M,
T,
W,
Th,
F,
Sa
four
days/week [check preferred days]:
Su,M,
T,
W,
Th,
F,
Sa
Every
day, all day that the facility is open for an intense
period of time
Whatever
the student wants
Other (please describe below:)
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We typically place
NP students with preceptors for an entire semester at a time.
What preference do you have for the semester(s) we place
students with you?
(please check all that apply)
Fall Semester
Spring Semester
Summer semester (this is typically our scheduled intense 360
hour practicum)
No preference (any semester is fine to place an NP student with
me)
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Student
Background: |
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Please mark all
student backgrounds that you feel are appropriate for rotations
at your facility. Keep in mind that all of our FNP students are
baccalaureate prepared, licensed RNs. |
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Novice RN with little work experience
RN
with non-primary care work experience (e.g., hospital or public
health)
RN
with primary care work experience (e.g., ER)
First year FNP student just learning about primary care and the
NP role
Second
year FNP student with some experience at NP student
FNP
student in final practicum (360 hours in 10 week period)
Other
(please describe):
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Would you like to meet or
interview FNP students before you agree to precept them?
Yes
No |
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Student
Involvement in Patient Care: |
Typically, FNP
students are advised to follow/shadow their preceptors for a day
or two at the beginning of each rotation before "diving into"
actual patient care. After this initial period, which of the
following statements best describes how you typically
incorporate students into patient care?
Please check ONE: |
Students
shadow me at all times
Students
interview and examine patients with me in the exam room at
all times
Students
interview patients independently but I am present during the
physical exam and plan
Students
interview and examine patients independently.
(They then report to me, and I go back in the patient's room and
deliver the plan of care with the student).
Students
interview and examine patients independently. They then report
back to me.
(We decide on the plan of care and the student delivers this
plan of care without my being present
Other
(Please describe below):
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Student
involvement in documentation (Are
students able to verbally dictate or chart at your facility?): |
Dictate?
Yes
No
Chart in handwriting?
Yes
No
Chart into a
computerized database??
Yes
No
Participate in other
forms of documentation?
Yes
No
If "Yes", describe
below:
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Types of Patients
& Type of Care Provided at Facility: |
Using the key below,
please complete the following table
to give us a better sense of the types of patients you see,
and the type of care you provide at your facility.
N = Never
R = Rarely
O = Occasionally
C = Commonly
F = Frequently
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Gender/age of Clientele |
Wellness/
Health Promotion |
Emergent Care |
Urgent
Care |
Chronic Disease Management |
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Boys/Men
(0-18 yrs) |
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Men
(19-35 yrs) |
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Men
(36-64 yrs) |
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Men
(65-79 yrs) |
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Men
(>80 yrs) |
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Girls/Women
(0-18 yrs) |
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Women
(19-35 yrs) |
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Women
(36-64 yrs) |
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Women
(65-79 yrs) |
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Women
(>80 yrs) |
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Specialty exams
and procedures experienced at facility: |
Using the same key
(below), please complete the
following list to give us a better sense of the specialty
exams and procedures students may experience at your facility:
N = Never
R = Rarely
O = Occasionally
C = Commonly
F = Frequently
Pelvic Exams
Prenatal Exams
Male STD exams
Endometrial biopsy
IUD insertion
Diaphragm fitting
Suturing
Incision & Drainage
Nail removal
Skin biopsies
Splinting
Joint injections
X-ray interpretation
EKG interpretation
Other:
Other:
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Expectations on
student preparation and presentations: |
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Please list
topics/areas that students should be
very
familiar with before joining you for a
rotation at your facility:
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Please list
topics/areas that students need to be
somewhat
familiar with before joining you for a
rotation at your facility:
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Depending on their
timing in the program,
we expect our students to give a succinct (<2 minutes),
organized verbal presentation to you after seeing patients,
including the patient's age and gender, CC, HPP, ROS,
pertinent past medical, social, and medication history,
pertinent objective findings, impression and/or list of
differential
diagnoses, and plan. If you have any other expectations
regarding student presentations, please describe them below:
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Other:
Is there anything
else you'd like to share with potential
FNP students about yourself, your expectations, or your
facility?:
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Thank You! |
