ࡱ> _a^ bjbj 4b P888,j(<<<<oqqqqqq$Z! $"88<<000d88<<o0o00:p{<raQx [0)R$x${{$00$ :  Instructions for Preceptor Approval Process Student contacts willing preceptor. Student performs licensee search on the appropriate board website to verify license and 2) check for any disciplinary action or encumbrances. For Nurse Preceptors, go to:  HYPERLINK "https://www.ncsbn.org/license-verification.htm" https://www.ncsbn.org/license-verification.htm For non- nurse preceptors (MD, DO, PA, mental health professions), go to the appropriate website. For Missouri providers, go to:  HYPERLINK "http://pr.mo.gov/healingarts-public-information.asp" http://pr.mo.gov/healingarts-public-information.asp Student downloads a copy of the preceptors license verification information and the disciplinary report showing that license is free of encumbrances. Student types information on the preceptor information form to the extent that the information is known. Student verifies accuracy of information and obtains any missing information. This step is always necessary, even if the preceptor has taken 91Ů students in the past. Student submits preceptor form according to course guidelines. Course coordinator will review the preceptor information and give approval if the preceptor is appropriate for the course. Student verifies with clinical agency if an affiliation agreement is required or if proof of enrollment and 91Ůs Certificate of Liability insurance is sufficient. If affiliation agreement is required, student submits Facility Contract Request form to ksaunde4@slu.edu When the legal arrangement is negotiated, the course coordinator is notified. Course coordinator notifies student that the clinical site is approved. 91Ů School of Nursing Preceptor Information Form Student Name Specialty Track (e.g. ACNP, FNP)Course Number Course CoordinatorSemester and YearPreceptor Contact InformationFull Name of PreceptorName of Clinical Site/Medical Group Street Address  Suite No., Department, Mail-Stop, Etc City, State, ZipOffice PhoneCell Phone (optional)FAX Number E-mail AddressOther contact informationBest Time & Preferred Method of ContactPreferred address for Verification of Precepting form (& thank you letter)Licensure/ Specialty Information*Send copies of license and other recognition documents. You must notify the School of any encumbrances or changes of status in your licensure or certification.Degree (s)License Type, State and Number Any current discipline to license? 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