Employee Preceptor Renewal Form

Employee Preceptor Renewal Form

Purpose: Use this form to apply for renewal of appointment as an Employee Preceptor. Complete all sections and attach required supporting documentation (current licenses, continuing education certificates, clinical precepting logs). Incomplete submissions may delay renewal review.

Personal Information

Employee ID:    Job Title:

Reporting Manager:    Manager Phone:

Position and Preceptor Status

Original Preceptor Appointment Date:    Requested Renewal Period (months):

Current Preceptor Status: Active Inactive Expired

Licensure and Certifications

License/Registration Type:    License Number:    State:

License Expiration Date:

Certifications (check all that apply):

BLS ACLS PALS NRP Other (specify below)

Continuing Education and Training

Provide CE completed since last renewal (attach certificates):

Mandatory Preceptor/Compliance Trainings Completed (check):

Preceptor Workshop Simulation Training Patient Safety Infection Control

Clinical Precepting Summary

Primary Clinical Areas (list units or services):

Total Precepting Hours Supervised in Last 12 Months:

Competency Self-Assessment

Please indicate whether you are current and competent in each area (Yes / No).

Clinical competence in assigned area: Yes No

Ability to provide effective feedback and evaluation: Yes No

Documentation and assessment of learner performance: Yes No

Employment History (most recent first)

Education

Professional References

Legal Disclosures and Authorizations

At-Will Employment: Renewal as a Preceptor is administrative and does not alter the at-will nature of employment. Nothing in this renewal application creates a contract of employment or modifies existing employment terms unless explicitly agreed in writing by authorized representatives.

Equal Opportunity: The organization maintains a policy of equal opportunity in all personnel actions. Preceptor appointments are made without regard to protected characteristics and based upon qualifications and demonstrated competence.

Authorization to Verify: I authorize the organization to contact previous employers, educational institutions, professional references, licensing boards, and credentialing entities to verify statements made on this form and to obtain records pertinent to my qualifications. I further authorize any such persons or entities to release information requested.

I consent to background checks, including but not limited to criminal background, employment verification, and license verification, as required for continued appointment as a Preceptor. I understand that adverse information may affect the renewal decision.

Applicant Certification and Attestation

I certify that all information provided on this form and accompanying documents is true, complete, and accurate to the best of my knowledge. I understand that falsification, omission, or misrepresentation of information may result in denial of renewal, disciplinary action, or termination.

Acknowledgment of Patient Safety and Professional Conduct

I acknowledge my duty to maintain patient safety, professional conduct, confidentiality, and adherence to organizational policies while acting as a Preceptor. I will promptly report any events or concerns that may affect learner or patient safety.

Supervisor Review (for administrative use)

Supervisor Name:    Supervisor Email:

Applicant Signature and Certification

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