PRECEPTORS Name and Credentials of Population Focus Certification* of Practice in # Students State Licensure/ Preceptor(s) at each site (& Specialty, if Specify Type & the Precepted Approval/ applicable) Area Certifying body (as or Concurrently Recognition* of Practice appropriate) Specialty Area 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. * Copy on file, as appropriate, or program/track has method of verifying documentation.
PRECEPTORS Name and Credentials of Preceptor(s) at each site Population Focus (& Specialty, if applicable) Area of Practice Certification* Specify Type & Certifying body (as appropriate) of Practice in the or Specialty Area # Students Precepted Concurrently State Licensure/ Approval/ Recognition* 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. * Copy on file, as appropriate, or program/track has method of verifying documentation.
ntfevalcriteria2012sampleforms.docx