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LCC Nursing Integrative Practicum Program (formerly Preceptor Program)
Clinical Teaching Associate (CTA) Participation Form

Clinical Teaching Associate 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 Integrative Practicum 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:

Clinical Teaching Associate Workshops

It is highly recommended that you attend one of the Clinical Teaching Associate workshops prior to working with your student. The workshops are being offered throughout the state. There is an information and registration link from the Clinical Teaching Associate main page.  A link will also be provided once you submit your CTA application.

You will need to arrange a time to meet with your assigned student if you are unable to attend one of the CTA workshops in Eugene. Please check one of the boxes below to indicate if you want to contact the student or would prefer to have the student contact you.  

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 30th to review your role as a CTA.

OTHER OPTIONS:

  • If you know a student you would like to work with 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 CTA please indicate below. A secondary CTA works with one or more students (and other CTA nurses) to increase the students' options in scheduling.
    I am only interested in being a secondary CTA.

    

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 1/27/09 (jhg)  
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