Undergraduate Preceptorship Request Form

To be filled out by instructor/faculty only

[ * Required fields ]

Instructor name:*

Email address: *

School: *

Student name: *

Student is an Aurora Employee:*
Yes No

Student is a second semester senior:*
Yes No

Hospital site request (does not guarantee placement): *

Inpatient nursing area (does not guarantee placement): *

Start date of semester clinical (mm/dd/yyyy): *

End date of semester clinical (mm/dd/yyyy): *

Required hours: *

School/faculty has read and understands the undergraduate preceptorship requirements.*