Preceptor Awards Nomination Form

Lakeridge Health is strongly committed to providing an exceptional learning environment for the development of students within the health professions. This achievement is only made possible through the effort of our staff to share their values, skills and knowledge. To celebrate the contributions our preceptors make throughout Lakeridge Health, we actively seek nominations for three Preceptor Awards.

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* Please fill out the following information about yourself:

Nominator's/Student's Name

Educational Institution

Contact Number

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* Please enter the start and end date of your Practicum:

Start

Date

End

Date

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* At which Lakeridge Health location did your Practicum take place?

Ajax-Pickering

Bowmanville

Oshawa

Port Perry

Whitby

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* Please choose the award you are nominating your preceptor for:

The Lakeridge Health Nursing Preceptor Award
Open to all staff who have acted as a Preceptor to a nursing student at Lakeridge Health.

The Lakeridge Health Non-Clinical Preceptor Award
Open to all staff who have acted as a preceptor to a college or university student from any non-clinical discipline or program at Lakeridge Health.

The Lakeridge Health Clinical Preceptor Award
Open to all staff who have acted as a preceptor to a college or university student from any clinical discipline or program at Lakeridge Health.

The Lakeridge Health Trainee Preceptor Award
Open to all staff who have acted as a Preceptor to an undergraduate medical student, postgraduate resident, or midwifery student at Lakeridge Health.

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* Please Fill out the Following About the Nominee

Name of Preceptor/Nominee

What is their extension?

Which Lakeridge Health Program are they a part of?

What is their discipline?

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* Briefly describe how long have you known the Nominee/Preceptor:

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* Tell us why you are nominating this preceptor (100 words or less)

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*
Please confirm the following:

I hereby confirm that I have nominated the above preceptor to be a potential recipient to the award selected.

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* Please fill out the following information about yourself:

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* Please enter the start and end date of your Practicum:

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* At which Lakeridge Health location did your Practicum take place?

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* Please choose the award you are nominating your preceptor for:

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* Please Fill out the Following About the Nominee

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* Briefly describe how long have you known the Nominee/Preceptor:

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* Tell us why you are nominating this preceptor (100 words or less)

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* Please confirm the following:

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Please confirm the following: