You are on page 1of 1

University of Michigan-Flint

School of Nursing
MSN 5 Preceptor Form
Full-Time: X Part-Time:

Directions: Student is to fill out the preceptor form completely, obtain preceptor’s signature, and submit to Blackboard.
Student Information:
Student Name: _______Theodore Krzysik____________________ Date: ____1/25/19________________________
UMID#: ___02058455____________University email: ______tkrzysik@umflint.edu__________________________
Phone Number: ______989-314-3193______________ Previous name used at Univeristy: _____________________
Employer: ______Ascension Standish Hospital_________ Unit/Floor/Area:___CCU/Acute Care/ER____________
Semester (one semester per form): _____Spring/Summer_ Year (semester year): _____2019_______________________
Course (one clinical course per form): ___NUR 521____ Number of Hours (with preceptor): ___168_____________
If you plan to complete your clinical hours at another site, you must complete a separate preceptor form and
your site must be approved by your clinical instructor.
Preceptor and Site Information:
Name of preceptor (as it appears on professional license): _____Stacey Anne Williamson___________________________
Preceptor email: ______sawfnp2011@gmail.com________ Credentials: ____RN, MSN, FNP-C___________________
Number of years in practice: ______4________________ Professional license number: ___4704248562_____________
Name of Preceptor’s facility: ________Standish Family Medicine_________________________________________
Office/Practice manager’s name: _____Ann Brown__________________ Phone number: ____989-846-3400________
Address of facility: ______805 W. Cedar Street_______________________________________________________
City: ____Standish________________________ State: _____MI____________ Zip code: _____48658____________
Phone number of facility: _____989-846-4888__________________________________________
Types of patients:
Type of clinical (e.g., acute, chronic,
supervision: (e.g., pediatrics, Family in-hospital, out- Adult/Pediatrics
family, adult) patient)

Student Signature:
By signing as the student: I agree to meet the clinical site requirements and meet on the assigned clinical days. If I am
unable to attend clinical, I will contact the preceptor immediately. I also understand that missed clinical days may result in
the inability to make up the hours and therefore delaying my progression in the program. Falsifying clinical hours may
result in removal from the program. **Note: Unsigned or inaccurate forms will not be processed.

Preceptor Signature:
By signing as the preceptor: I understand I must be physically present in the setting with the student during all clinical
hours. I agree to contact the student if I cannot be present on a scheduled clinical day and I understand I cannot
permanently assign the student to another provider in my absence.

The preceptor form must be accompanied with the preceptor’s CV/Resume and Professional License #. Submit form in Blackboard under the Clinical
Placement Shell for approval. Questions? Please email Peggy Sheffer Clinical Coordinator at