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Preceptorship Prescreen Checklist - 6552
IMPORTANT INSTRUCTIONS: This prescreen checklist may be used to check if a preceptor and practicum site may be appropriate for this practicum course. The questions included in this prescreen checklist are asked because they relate to the requirements for practicum sites and preceptors for this course. If your answer to a question is other than the option(s) provided, this means that the preceptorship will not meet the requirement. If your preceptor and/or practicum site do not meet the requirements listed on this checklist, the preceptorship will not qualify for this course.
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I understand these instructions.
Specialization:
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Please select
Adult Gerontology Primary Care Nurse Practitioner
Family Nurse Practitioner
Practicum Course:
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Please select
PRAC 6552
PRCM 6552
What license or certification does this preceptor hold?
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Please select
APRN - AGPCNP
APRN - ANP
APRN - FNP
APRN - WHNP
MD
DO
PA
What license or certification does this preceptor hold?
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Please select
APRN - FNP
APRN - WHNP
MD - OB and/or GYN
DO - OB and/or GYN
PA
I understand that by precepting with a MD, DO, or PA for this course, I must precept with NP preceptors for two of my four practicum courses.
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Please select
Yes
I have reviewed the regulations of my state Board of Nursing, and they allow Physician Assistants (PA) to serve as preceptors for APRN Nurse Practitioner practicum experiences.
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Please select
Yes
This preceptor has an active unencumbered license in the state of the practicum site.
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Please select
Yes
I have completed a review of the preceptor's license through the state board website and have confirmed this preceptor does not have current or past action on their license, including board orders, letters of reprimand, letters of censure, complaints, malpractice claims, monitoring program, sanctions, disciplinary action, and other action taken against the license by the state licensing board.
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Please select
Yes
I have reviewed the list of Restricted States in the Practicum Manual (https://academicguides.waldenu.edu/nursing-field/restricted-states) and confirm I can complete a practicum for my program in the state where the practicum site and patients are located.
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Please select
Yes
This preceptor has either a master's or doctoral degree in their area of specialization.
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Please select
Yes
This preceptor has a minimum of one year of postgraduate unsupervised experience after they were originally licensed.
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Please select
Yes
This preceptor is a full permanent employee of the practicum site.
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Please select
Yes
No, but the preceptor works under a contract and has confirmed the site will approve the preceptorship.
This preceptor practices in reproductive health care.
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Please select
Yes
This preceptor provides assessment and management of women's healthcare needs, pap smears, GYN management, and STD management.
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Please select
Yes
This preceptor provides obstetrical and/or gynecological care. This preceptor also focuses on women's healthcare, family planning, and reproductive services.
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Please select
Yes
This preceptor sees women ages 13 and older and provides reproductive healthcare along with primary care services.
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Please select
Yes
This preceptor sees women of all ages and provides reproductive healthcare along with primary care services.
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Please select
Yes
What type of setting is the practicum site?
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Please select
OB and/or GYN Practice/Clinic
Family Practice
Internal Medicine Practice
Primary Care Clinic
Health Department Clinic
Planned Parenthood
This practicum site provides a minimum of 50% women's care, including services in the area of GYN, Pap smears, birth control, perimenopause, menopause, and STDs.
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Please select
Yes
No, but I will have an additional preceptor to serve as a supplemental preceptor to complete all the course requirements.
What type of practicum experience will this be?
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Please select
Onsite Patient Care
Telehealth Patient Care
Onsite & Telehealth Patient Care
For telehealth, I understand that both my preceptor and I must be onsite at the practicum site face-to-face with my preceptor while conducting telehealth patient appointments. I have read the Telehealth Policy in the Practicum Manual, and this preceptorship will meet the policy for telehealth.
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Please select
Yes
For telehealth, I understand that I can only complete 25% of practicum hours with patients via telehealth and I must complete 75% of practicum hours doing onsite patient visits.
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Please select
Yes
For telehealth only, I understand that I can't complete this practicum course via telehealth only and I must have another preceptorship to complete direct patient care in person and onsite at the site with patients for 75% of my practicum hours.
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Please select
Yes
I understand that I must complete 160 practicum hours and have 100 patient encounters for this course.
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Please select
Yes
This preceptor serves enough patients that are women aged 13 years or older for me to meet the patient encounter requirements of 100 patients.
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Please select
Yes
No , but I will have an additional preceptor to serve as a supplemental preceptor to complete all the patient encounters to meet the requirements.
This preceptor serves enough patients that are women of all ages for me to meet the patient encounter requirements of 100 patients.
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Please select
Yes
No , but I will have an additional preceptor to serve as a supplemental preceptor to complete all the patient encounters to meet the requirements.
This preceptor performs internal vaginal exams and breast exams.
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Please select
Yes
No , but I will have an additional preceptor to serve as a supplemental preceptor to complete this requirement.
I understand that I am NOT to be involved in or observe births or surgeries.
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Please select
Yes
I have confirmed with the preceptor that I will be the only student they would be precepting on the days when I am present at the site to guarantee I will have a 1:1 preceptor to student ratio during this practicum experience.
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Please select
Yes
I understand that I must complete the required practicum hours and patient encounters for this course by Week 10 of the course. I understand that I must complete practicum hours over a minimum of 8 weeks.
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Please select
Yes
Are you employed at the practicum site?
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Please select
No
Yes
As an employee at the practicum site, I understand that this practicum experience must be in a different department/unit than where I currently work.
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Please select
Yes
As an employee at the practicum site, I understand that this practicum experience must be completed during different hours than my work schedule?
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Please select
Yes
Is this preceptor your work supervisor or manager?
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Please select
No
I understand that I must complete this practicum experience on site at the official place of business for the practicum site. I understand I am not permitted to conduct home visits/appointments. I also understand that I am not permitted to complete practicum in the preceptor's residential setting.
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Please select
Yes
I attest that I do not have a relationship with this preceptor that would be considered a conflict of interest. (e.g. This preceptor is not my relative, family member, fiancé, roommate, significant other, personal friend, primary care provider, a current Walden student, or any other relationship that would be a conflict of interest.)
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Please select
Yes
Student Name:
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First
Last
Student ID:
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Student Walden Email:
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I attest that I answered these questions correctly and accurately. I understand the results of this prescreen checklist is based on the responses I selected. I understand that if I answered the questions incorrectly, these results are invalid.
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Yes
I understand that this is only a prequalification checklist to assist me in checking if a potential preceptor and site may be appropriate for a course for the current academic year based on the requirements in the current Practicum Manual and does not guarantee practicum approval.
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Yes
I understand that I must submit a practicum application in Meditrek and my preceptor must complete the Preceptor Commitment Form by the application deadline.
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Yes
I understand the Office of Field Experience must complete a review of the practicum site and preceptor to vet this preceptorship after I submit my practicum application to confirm the preceptorship will meet the practicum requirements.
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Yes
Signature
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Clear
