Agency/Preceptor Request Form

MSN Student Agency Request Form

Please read instructions before completing form. Students are responsible for ensuring accurary of information provided. Inaccurate information will delay the process and may impact on the student's ablity to progress in the program. It is recommended the sudent submit this form least 3 weeks prior to anticipated start date. Students cannot begin clinical unitl notified via Marshall University email that an affiliation agreement with the agency is in place. Clnical hours completed before the affiliation agreement is in place will not be counted towards the course requirement. Additionally, the student is not covered by University malpractice insurance without a signed agency affiliation agreement in place.

I have read all instructions and information before completing this form:

yes

Name

First Last

Date Submitted for Processing:

Student ID Number (MUID)

Student Phone Number(s)

Course Number (Pick from below)(Required)

Semester

Preceptor's Title

Preceptor's Name

First Last

Preceptor's Email

Credentials MD/DO/NP/BSN/MSN/DNP or other (please specify)

How many hours do you plan on being with this preceptor?

Hours are requested for:

If Speciality, what speciality?

Agency Name

Agency Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Agency Contact Person

First Last

Agency Phone Number

Agency Contact Email