Preceptor Agreement form

Preceptor Agreement Form

SITE INFORMATION State Zip

Site Name
Address
City

PRECEPTOR INFORMATION

Preceptor Name

Preceptor License #

Board Certified Yes No Certification #
Start Date:
Certifying Board

Preceptor's Work Telephone #

Term Year

I agree to work with ___________________, an MSN student at Drexel University College of
Nursing and Health Professions, for _____ hours. My relationship will assist the student to
achieve clinical/practicum objectives that are part of the course requirements in which he/
she is enrolled. I agree to provide direct supervision and guidance to the student and to par-
ticipate in his/her clinical evaluation.

Preceptor Signature:
Date

Clinical/ Practicum Conflict of Interest Form

This form is required for all students.

The student understands that a clinical/practicum placement in their place of employment is a
potential conflict of interest that must be actively managed by the program, student and
student's employer. By signing and dating this document, the student understands and agrees
to the clinical/practicum guidelines stated below.

The student also understands that failure to comply with these guidelines may result in having
to repeat clinical/practicum hours, loss of academic credit for the placement, assignment to an
alternative placement and/or other appropriate action at the discretion of the track director or
program chair.

1. Regular work hours do not count for clinical or practicum hours.
2. Work and clinical/practicum hours must be on different shifts or days.
3. Roles must be clearly defined and practiced independently from each other. For

example, while on clinical duty as a student, the student is not permitted to
perform any work/job-related activities or duties.

4. Preceptor cannot be an employee from the student’s work department/unit, friend
or relative, or an immediate supervisor.

5. The student is not permitted to see patients on their work unit during their
clinical/practicum hours.

6. There must be a physical separation between work and student clinical
environments. Clinical/practicum and work environments must not be adjacent to
each other. Settings must be separated by at least one floor or unit.

7. If any of the above guidelines are not complied with at any time during the
clinical/practicum placement, the student is required to report the non-
compliance to the track director within 48 hours.

Preceptor Student

Print Name Print Name
Date Date