1. Complete all parts of the form
  2. Click "Submit" to submit the form
  3. Print a copy of "Form Confirmation" for your records
  4. Complete, submit and print one form for each potential preceptor & clinical facility/agency
Previous Clinical Courses Taken: NURS 522:     NURS 524:     NURS 526  NURS 528:     NURS 530:    

Student Information

First Name:
Last Name:
Student ID #:
Work Phone:
Home Phone:
AU Student E-mail:

Facility Information

Facility Name:
Facility Address:
(including postal code)
Facility Phone:
Facility FAX:
Facility Health Authority/Region:
Web address (URL) if available:
Are you an employee of this Authority Region YES:     NO:    
Is this the first time you have completed a practicum in this facility YES:     NO:    

Contact Person Information

First Name:
Last Name:
Position Title:
Mailing Address:
(including postal code)

Preceptor Information

First Name:
Last Name:
Professional Designation:
Highest Educational Qualification: (i.e. BN/BScN, MD, MN, PhD/DNP, Other)
Mailing Address:
(including postal code)
Is this the first time you have completed a practicum with this preceptor YES:     NO:    
I am aware that a potential preceptor may NOT be a relative or close friend (including husband/wife relationships, cousins and family friends), and I acknowledge that my preceptor meets the approved criteria. YES:    

Course Information

The above person has agreed to be considered as a preceptor for the extended health services practicum for the following courses (Check course(s) specific to this term):

NURS 522:     NURS 524:     NURS 526  NURS 528:     NURS 530:     NURS 695:    

Dates you will be completing a practicum in the facility:
(Use format: From - To | MM/DD/YY - MM/DD/YY)
Number of hours requested with this preceptor:
This is request #: 1:     2:    
All clinical prerequisites are up to date: YES:     NO:    
Returning from more than one term absence: YES:     NO:     if "Yes" please contact your Clinical Coordinator;
Release Indemnity Agreement submitted to contract administrator: YES:     NO:    
Fax: 780-675-6813 (Students from provinces Sask., Manitoba, NFL., N.S., N.B., P.E.I.);


The personal information collected on this form will be used for the purpose of preparing a practicum agreement between Athabasca University and the health agency for the preceptor(s) involved in the Extended Health Services practicum of the student in the Advanced Nursing Practice program. This information is collected under the authority of Section 33(c) of the Alberta Freedom of Information and Protection of Privacy Act. If you have any questions about the collection and use of this information, please contact the Director, Centre for Nursing and Health Studies, Athabasca University. Telephone 780-675-6381.