Clinical Preceptor Registration

Name: *

How many years have you been a nurse? *

1-5 years

6-10 years

11-15 years

15+ years

Prior certification/licenses before becoming an RN? *

CNA

LPN

N/A

Which facility do you work at? *

Unit:

Highest Degree Held: *

Where did you receive your RN? *

If you have received a BSN, where from?

If you received an MSN, where from?

Speciality: *

Email Address: *

Personal Phone Number: *Include area code

Unit Phone Number: *

Please indicate your shifts: *

Days

Evenings

Weekends

Days & Evenings

Evenings & Weekends

Where did you hear about us? *

For training purposes, have you been a preceptor before? *

Did you graduate from CCRI? *

Yes

No

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Clinical Preceptor Registration