ND Center for Nursing APRN Preceptor Bureau Application Survey

Thank you for your interest in joining the ND Center for Nursing APRN Preceptor Bureau. The questions below are designed to determine your eligibility to participate in the program, to gather participant tracking information and to gather information for listing on our password protected Preceptor Bureau website. Those items that will be shared on the Bureau website are marked below. Once we receive and have reviewed your application, we will send you a link within 48 hours to the online webinar and to the Preceptor Bureau website.

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* 1. Contact Information. This Contact Information will be shared on the Preceptor Bureau website.

Name:

Company:

Address:

Address 2:

City/Town:

State:

ZIP:

Email Address:

Phone Number:

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* 2. Year Graduated with APRN degree

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* 3. Degree This question will be shared on the preceptor bureau page.

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* 4. College/University

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* 5. APRN Practice Area (population/specialty). This question will be shared on the Preceptor Bureau website.

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* 6. Present position/job description

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* 7. Years of Experience

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* 8. Professional Affiliations

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* 9. License Restrictions

Yes

If Yes, please explain

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* 10. Contact person/email/phone to contact regarding initiating preceptor/preceptee matching at your employer organization. Please list yourself if that is the way your health care facility is organized. (Note- many facilities require matching the preceptee with preceptors be conducted through the education department or human resources. Please provide this contact so that academic institutions can communication with the appropriate person. This information will be included on the Preceptor Bureau website.

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* 11. The questions below are designed to determine your current knowledge, skills, abilities and judgement for several aspects of precepting. Do not worry if you find that you do not score highly on several of these. We are using these to establish a baseline for our program. The preceptor webinar includes several of these and additional resources will provide more opportunity to fill in gaps.

	little to no knowledge, skills, abilities, judgement	minimal	some	good	expert level knowledge, skills, abilitities, judgement
Adult Learning Theory	Adult Learning Theory little to no knowledge, skills, abilities, judgement	Adult Learning Theory minimal	Adult Learning Theory some	Adult Learning Theory good	Adult Learning Theory expert level knowledge, skills, abilitities, judgement
Transformative Learning Theory	Transformative Learning Theory little to no knowledge, skills, abilities, judgement	Transformative Learning Theory minimal	Transformative Learning Theory some	Transformative Learning Theory good	Transformative Learning Theory expert level knowledge, skills, abilitities, judgement
Social Learning Theory	Social Learning Theory little to no knowledge, skills, abilities, judgement	Social Learning Theory minimal	Social Learning Theory some	Social Learning Theory good	Social Learning Theory expert level knowledge, skills, abilitities, judgement
Hierarchy of Needs Theory	Hierarchy of Needs Theory little to no knowledge, skills, abilities, judgement	Hierarchy of Needs Theory minimal	Hierarchy of Needs Theory some	Hierarchy of Needs Theory good	Hierarchy of Needs Theory expert level knowledge, skills, abilitities, judgement
Benner's Novice to Expert Theory	Benner's Novice to Expert Theory little to no knowledge, skills, abilities, judgement	Benner's Novice to Expert Theory minimal	Benner's Novice to Expert Theory some	Benner's Novice to Expert Theory good	Benner's Novice to Expert Theory expert level knowledge, skills, abilitities, judgement
Learning Styles	Learning Styles little to no knowledge, skills, abilities, judgement	Learning Styles minimal	Learning Styles some	Learning Styles good	Learning Styles expert level knowledge, skills, abilitities, judgement
Teaching strategies	Teaching strategies little to no knowledge, skills, abilities, judgement	Teaching strategies minimal	Teaching strategies some	Teaching strategies good	Teaching strategies expert level knowledge, skills, abilitities, judgement
Learning taxonomies	Learning taxonomies little to no knowledge, skills, abilities, judgement	Learning taxonomies minimal	Learning taxonomies some	Learning taxonomies good	Learning taxonomies expert level knowledge, skills, abilitities, judgement
Communication	Communication little to no knowledge, skills, abilities, judgement	Communication minimal	Communication some	Communication good	Communication expert level knowledge, skills, abilitities, judgement
Critical thinking, judgment, reasoning, confidence building	Critical thinking, judgment, reasoning, confidence building little to no knowledge, skills, abilities, judgement	Critical thinking, judgment, reasoning, confidence building minimal	Critical thinking, judgment, reasoning, confidence building some	Critical thinking, judgment, reasoning, confidence building good	Critical thinking, judgment, reasoning, confidence building expert level knowledge, skills, abilitities, judgement
Competency evaluation	Competency evaluation little to no knowledge, skills, abilities, judgement	Competency evaluation minimal	Competency evaluation some	Competency evaluation good	Competency evaluation expert level knowledge, skills, abilitities, judgement
Using plans and objectives in evaluation	Using plans and objectives in evaluation little to no knowledge, skills, abilities, judgement	Using plans and objectives in evaluation minimal	Using plans and objectives in evaluation some	Using plans and objectives in evaluation good	Using plans and objectives in evaluation expert level knowledge, skills, abilitities, judgement
Coaching principles	Coaching principles little to no knowledge, skills, abilities, judgement	Coaching principles minimal	Coaching principles some	Coaching principles good	Coaching principles expert level knowledge, skills, abilitities, judgement
Generational differences	Generational differences little to no knowledge, skills, abilities, judgement	Generational differences minimal	Generational differences some	Generational differences good	Generational differences expert level knowledge, skills, abilitities, judgement
Evaluation and feedback	Evaluation and feedback little to no knowledge, skills, abilities, judgement	Evaluation and feedback minimal	Evaluation and feedback some	Evaluation and feedback good	Evaluation and feedback expert level knowledge, skills, abilitities, judgement
My specific practice area	My specific practice area little to no knowledge, skills, abilities, judgement	My specific practice area minimal	My specific practice area some	My specific practice area good	My specific practice area expert level knowledge, skills, abilitities, judgement
Dealing with difficult people and poor performance	Dealing with difficult people and poor performance little to no knowledge, skills, abilities, judgement	Dealing with difficult people and poor performance minimal	Dealing with difficult people and poor performance some	Dealing with difficult people and poor performance good	Dealing with difficult people and poor performance expert level knowledge, skills, abilitities, judgement
My particular employment setting's policy and procedure related to precepting	My particular employment setting's policy and procedure related to precepting little to no knowledge, skills, abilities, judgement	My particular employment setting's policy and procedure related to precepting minimal	My particular employment setting's policy and procedure related to precepting some	My particular employment setting's policy and procedure related to precepting good	My particular employment setting's policy and procedure related to precepting expert level knowledge, skills, abilitities, judgement
National standards of practice/performance	National standards of practice/performance little to no knowledge, skills, abilities, judgement	National standards of practice/performance minimal	National standards of practice/performance some	National standards of practice/performance good	National standards of practice/performance expert level knowledge, skills, abilitities, judgement
State (ND) nursing practice regulations	State (ND) nursing practice regulations little to no knowledge, skills, abilities, judgement	State (ND) nursing practice regulations minimal	State (ND) nursing practice regulations some	State (ND) nursing practice regulations good	State (ND) nursing practice regulations expert level knowledge, skills, abilitities, judgement

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* 12. Please indicate your current availability to serve as a preceptor. Please contact Patricia Moulton if you will need this to change in the future.

Available

Not available