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RNBRP Preceptor Information Form
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RNBRP Preceptor Information Form
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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)
Verify you are not a robot