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Preceptorship Prescreen Checklist - 8601
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
DNP - General Traditional
DNP - Executive Leadership
Practicum Course:
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Please select
NURS 8601
I have met with my Student Success Advisor to determine how many practicum hours I need for NURS 8601 to meet the minimum of 1,000 post-baccalaureate practicum hours for the DNP program.
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Please select
Yes
I understand that I can only enroll in 3 credits of NURS 8601 per term.
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Please select
Yes
I understand that I must complete 80 practicum hours for one credit of NURS 8601.
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Please select
Yes
I understand that I cannot provide direct patient care during my practicum experiences in NURS 8601.
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Please select
Yes
I understand some possible examples of practicum experiences for NURS8601 include experiences in quality improvement, health policies and innovation, leadership, informatics, and staff education.
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Please select
Yes
What license or certification does this preceptor hold?
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Please select
RN
APRN (NP or CNS)
N/A - Not Licensed as a Nurse
What non-nurse license or certification does this preceptor hold?
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Please select
N/A - Not Licensed or Certified
MD/DO
MD/DO - Psychiatrist
Licensed Psychologist
Physician Assistant
Physical Therapist
Licensed Counselor or Social Worker
Other - Licensed or Certified in the healthcare field not listed
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 a master's or doctoral degree in a field related to my practicum goals.
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Please select
Yes
This preceptor has a minimum of one year of experience in the field/specialization after they were originally licensed.
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Please select
Yes
The preceptor is employed at a facility in the healthcare industry.
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Please select
Yes
The preceptor currently works in a role and has expertise in a field that is relevant to my area of interest for my practicum goals and objectives for this course that will help advance my knowledge and skills.
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Please select
Yes
I understand that I am not permitted to do direct patient care for this practicum experience.
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Please select
Yes
This preceptor will be able to provide me support to complete 80 practicum hours for each credit of NURS 8601 for this course.
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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 required hours.
I attest that this preceptor is not an educator at a university, college, or other educational institution.
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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.
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. 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
