Preceptor agreement form Preceptor name and credentials Facility

Preceptor agreement form
Preceptor name and credentials ______________________________________________
Facility name ____________________________________________________________
City/State ______________________________________________________________
Position title_____________________________________________________________
Email address ___________________________________________________________
Phone _________________________________________________________________
Preceptor responsibilities
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Scheduling appropriate experiences to meet rotation competencies
Orient the intern to the facility and expectations
Evaluating intern using form provided
Being familiar with and abiding by the UH Dietetic Internship policies and
procedures
• Communicate with UH internship director regarding intern progress
• Mentoring and providing daily supervised learning experiences for intern
I agree to be a preceptor for _____________________________________ if
accepted to the University of Houston Distance Internship
Preceptor signature and date