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):
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 #:
All clinical prerequisites are up to date:
Returning from more than one term absence:
NO:   if "Yes" please contact your Clinical Coordinator;
Release Indemnity Agreement submitted to contract administrator:
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.