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LCC Nursing Preceptor Program
Participation Form

Preceptor Participation information can be submitted online using this form.
Type into the open boxes, or where there are choices listed click the appropriate response.
Please click the Submit button at the end of the form. The information is emailed directly to the Preceptor Coordinator and will not be used for any other purpose. As always mail-in forms are available on the nursing units if you prefer.

Your name:
Your email:
Year of graduation from nursing school:
Hospital/Agency where employed:

Unit:

Shift:

Usual Hours of work per week:

Work phone:

Home phone:

PRECEPTOR PREPARATORY MEETINGS

New preceptors:

Lane faculty have an hour orientation meeting with new LCC preceptor nurses to distribute Preceptor Handouts and review the basics of this program. "Your" student attends the last 20 minutes to meet you and establish a tentative preceptor schedule from your work schedule. (Please bring your work schedule from April through mid-May if available). Your agency has agreed to pay you for this time.

Please indicate your choice from the list of options given.

If need to change day and/or time later please contact Sue Roders so that the student will be notified not to come at that time.

SHMC Wed, March 12 1345-1445 Conference Room A
SHMC Wed, March 12 1545-1645 Conference Room A
SHMC Fri, March 14 1345-1445 Conference Room A
SHMC Fri, March 14 1545-1645 Conference Room A

MKW Wed, March 12 1430-1530 Mohawk Room
MKW Wed, March 12 1630-1730 Mohawk Room
MKW Fri, March 14 1430-1530 Metolious Room
MKW Fri, March 14 1630-1730 Metolious Room

I don't know my work schedule. Please contact me later with these options.

Experienced preceptors:

Nurses who have been LCC preceptors in the past will meet independently with "their" student during the week of March 10-14. The student will bring you a Preceptor Notebook for your review to that meeting. Please indicate your preference how you wish to make contact with your student:

I will meet with my student to establish a schedule, and I give permission to release my phone to that student.
I will meet with my student to establish a schedule, but prefer to contact my student directly. Please send student name and phone number when that becomes available.

Your faculty liaison will meet with you after March 31st to review your role as a preceptor.

OTHER OPTIONS:

  • If you know a student you would like to precept please include that name in this box. Faculty will make that placement if at all possible within the Lane rules of registration.
    Student name:
  • If you are only interested in being a secondary preceptor please indicate below. A secondary preceptor works with one or more students (and other preceptor nurses) to increase the students' options in scheduling.
    I am only interested in being a secondary preceptor.

    

THANK YOU. If you had any difficulty with this form please email Sue Roders at roderss@lanecc.edu, or (541) 463-3199.

Lane Community College - Health Professions
4000 East 30th Ave Eugene, OR 97405 | Main Campus, Building #4
Phone: 541-463-5617 | Fax: 541-463-4151
Please direct comments about this site to dietzc@lanecc.edu
Revised 4/15/08 (jhg)  
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