Preceptor Information Identify your role(Required) Student Preceptor Preceptor InformationName(Required) First Last Highest degree awarded (MHS, MBA, MD):(Required)College/University which granted degree(s):(Required)Date degree awarded(Required)Total years of healthcare leadership experience(Required)Title(Required)Employer(Required)Employer Phone Number(Required)Employer Email(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Student's Name(Required) First Last Student InformationStudent Name(Required) First Last UAMS Course Number(Required)Term(Required)SpringSummerFallYear(Required)Preceptor's Name(Required) First Last Preceptor AgreementPreceptor agrees to: 1. Discuss learning objectives with the student. 2. Serve as a role model for the student. 3. Provide orientation to the experiential learning for the student. 4. Supervise the student’s activities and performance in the preceptorship relationship and advise the student in the transition into professional practice and professional development needs. 5. Assist the student in revising unreachable goals and objectives or those that are not feasible. 6. Contact faculty advisor if needed to handle student experience or performance issues. 7. Write an evaluation of student performance at the end of the experiential learning. 8. Be available to support the student. Student agrees to: 1. Request experiential learning in an area where not presently or previously employed except by permission of faculty. 2. Develop specific goals and objectives for the experiential learning. Give copies of the syllabus to the preceptor. 3. Plan schedules with preceptor to meet course requirements, based on preceptor’s employment schedule beginning as soon as possible. 4. Attend meeting(s) with preceptor and faculty to review experiential learning. 5. Adhere to policies and procedures of both the University of Arkansas for Medical Sciences and the organization. 6. Inform the faculty advisor of any problems as soon as possible following the occurrence. 7. Inform faculty advisor of any need for absence or schedule variation (before the change of schedule) of student or preceptor. Faculty agrees to: 1. Meet with the student and preceptor to plan the experiential learning. 2. Collaborate with the student to determine the feasibility of the student’s learning objectives. 3. Meet with student and/or preceptor to discuss progress toward goals. 4. Meet with student and preceptor to assist student toward behavioral change if performance is unsatisfactory. 5. Determine satisfactory completion with the student for the experiential learning. Preceptor Acknowledgment(Required) I hereby agree to serve as a preceptor and agree to the expectations listed above.Date(Required) Student AgreementPreceptor agrees to: 1. Discuss learning objectives with the student. 2. Serve as a role model for the student. 3. Provide orientation to the experiential learning for the student. 4. Supervise the student’s activities and performance in the preceptorship relationship and advise the student in the transition into professional practice and professional development needs. 5. Assist the student in revising unreachable goals and objectives or those that are not feasible. 6. Contact faculty advisor if needed to handle student experience or performance issues. 7. Write an evaluation of student performance at the end of the experiential learning. 8. Be available to support the student. Student agrees to: 1. Request experiential learning in an area where not presently or previously employed except by permission of faculty. 2. Develop specific goals and objectives for the experiential learning. Give copies of the syllabus to the preceptor. 3. Plan schedules with preceptor to meet course requirements, based on preceptor’s employment schedule beginning as soon as possible. 4. Attend meeting(s) with preceptor and faculty to review experiential learning. 5. Adhere to policies and procedures of both the University of Arkansas for Medical Sciences and the organization. 6. Inform the faculty advisor of any problems as soon as possible following the occurrence. 7. Inform faculty advisor of any need for absence or schedule variation (before the change of schedule) of student or preceptor. Faculty agrees to: 1. Meet with the student and preceptor to plan the experiential learning. 2. Collaborate with the student to determine the feasibility of the student’s learning objectives. 3. Meet with student and/or preceptor to discuss progress toward goals. 4. Meet with student and preceptor to assist student toward behavioral change if performance is unsatisfactory. 5. Determine satisfactory completion with the student for the experiential learning. Student Acknowledgment(Required) I hereby agree to expectations listed above for the course and term listed.Date(Required)
