Instructor data form

Please fill out on an annual basis or as changes occur.

* Required fields

School:
Instructor's name:*
Semester in nursing program:
Course title:
Goals of clinical experience:
Responsibilities and role of the students during the course:
Role of staff Nurse:
Role of Instructor:
Date of clinical semester:
Days and hours on unit:
Any skills not permitted:
Area of expertise of instructor:
Phone contact:*
Email contact:*