RNBRP Preceptor Information Form

First Name:

Last Name:

Street Address:

City:

Province:

Postal Code:

Home Phone:

Work Phone:

Email Address:

Professional Designation:

Years of Experience:

Current Health District

Central - NSHA

Eastern - NSHA

Northern - NSHA

Western - NSHA

IWK

PEI

Other

Facility:

Practice Setting:

Have you taken the Learning Institute Preceptor Development Program

Yes

No

If yes, when? (mm/yy)

Have you taken another preceptor development program?

Yes

No

If yes, when? (mm/yy)

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