EmailMe Form - Preceptorship Prescreen Checklist

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. *

I understand these instructions.

Specialization: *

Practicum Course: *

I understand that if I need help with understanding if this preceptor's license will meet the requirements for this course, I may send an email to nursingfield@mail.waldenu.edu to confirm if the license will meet the requirements of the course. *

I have reviewed the preceptorship requirements of my state Board of Nursing and have confirmed the following: *

NOTE: You may review regulations and requirements for APRN licensure on the state board of nursing website or contact the state board of nursing.

The state that I checked that requires preceptors to be either an APRN (NP) or MD and does not permit other types of preceptors is: *

What license or certification does this preceptor hold? *

What license or certification does this preceptor hold for a state that requires an APRN or MD? *

I have verified that this preceptor is board-certified in psychiatry. I understand that a M.D. or D.O. preceptor will not qualify unless the preceptor has received a board certification in psychiatry. *

I have verified that this preceptor is certified as a PMHNP. I understand that an APRN/NP preceptor will not qualify unless the preceptor has received certification in PMHNP. *

This preceptor has a license that allows the preceptor to practice independently and is not under supervision. I have reviewed the preceptor's license type through the state board website and have confirmed this license allows the individual to practice unsupervised. *

NOTE: Every state is different with license titles and scope of practice, so it is important to confirm and verify if the preceptor is practicing under supervision.

This preceptor has a license that allows the individual to practice clinical psychotherapy. I have reviewed the preceptor's license type through the state board website and have confirmed this license allows the individual to practice clinical psychotherapy. *

NOTE: Every state is different with license titles and scope of practice, so it is important to confirm and verify if the preceptor is permitted to practice clinical psychotherapy.

This preceptor has an active unencumbered license in the state of the practicum site. *

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. *

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. *

This preceptor has either a master's or doctoral degree in the area of psychiatric mental health. *

This preceptor has a minimum of one year of postgraduate unsupervised experience after they were originally licensed. *

This preceptor is a full permanent employee of the practicum site. *

This preceptor provides clinical psychotherapy services. I understand that clinical psychotherapy services include utilizing clinical psychotherapy skills; psychological theories; and psychotherapeutic techniques and interventions for the treatment of mental health conditions and psychiatric/psychological disorders utilizing multiple modalities (e.g. cognitive behavioral, behavioral, humanistic, psychoanalytical, psychodynamic, constructionist, systemic, interpersonal, holistic, etc.). *

This preceptor provides clinical psychotherapy services with multiple modalities to include individuals, families, and groups. *

What type of setting is the practicum site? *

What type of practicum experience will this be? *

This preceptor serves enough patients for me to complete 160 practicum hours and have 80 patient encounters. *

This preceptor serves patients across the lifespan for me to meet the course requirements. This preceptor serves enough patients for me to meet the patient encounter requirements of seeing a minimum of 5 patient encounters in all the four age categories of 0-12 years, 13-17 years, 18-64 years, and 65+ years. *

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. *

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. *

Are you employed at the practicum site? *

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. *

As an employee at the practicum site, I understand that this practicum experience must be completed during different hours than my work schedule? *

Is this preceptor your work supervisor or manager? *

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.) *

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. *

Student Name: *

First Last

Student ID: *

Student Walden Email: *

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. *

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. *

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. *

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. *

Yes

Signature *

Clear