Nurse Preceptor Log & Verification Form
Preceptor Name
*
First Name
Last Name
Preceptor Email
*
example@example.com
Practice site
*
(Location where hours were completed)
Unit
*
(Unit where precepting took place)
Student Name
*
First Name
Last Name
Student Email
*
example@example.com
Academic Institution
*
Weekly Time Log
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Total hours for week
8/1/2024-8/3/2024
8/4/2024-8/10/2024
8/11/2024-8/17/2024
8/18/2024-8/24/2024
8/25/2024-8/312/2024
9/1/2024-9/7/2024
9/8/2024-9/14/2024
9/15/2024-9/21/2024
9/22/2024-9/28/2024
9/29/2024-10/5/2024
10/6/2024-10/12/2024
10/13/2024-10/19/2024
10/20/2024-10/26/2024
10/27/2024-11/2/2024
11/3/2024-11/9/2024
11/10/2024-11/16/2024
11/17/2024-11/23/2024
11/24/2024-11/30/2024
12/1/2024-12/7/2024
12/8/2024-12/14/2024
12/15/2024-12/21/2024
Please select SAVE after entering your weekly hours for continued access to form. NOTE: Do not click submit until you are ready for final approval of hours.
If you have any questions, please contact us at preceptorincentiveprogram@tha.com
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Once you have completed the preceptorship for the student indicated above and are ready for final approval, please review your form. Please make sure you have entered total precepted hours and confirmed coordinator/approver name and email below. When ready to submit for approval click SAVE and then click SUBMIT and your log will be sent to the clinical coordinator for approval and signature.
If you have any questions, please contact us at preceptorincentiveprogram@tha.com
Please enter total hours from log.
*
Before submitting to the clinical approver please enter your total number of precepted hours for this student.
I attest that the above hours are true and correct for the precepted clinical experience.
*
Clinical Coordinator Name (Academic institution approval)
*
First Name
Last Name
Clinical Coordinator Email
*
example@example.com
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