Nursing Clinical Transition Preceptor Request

Contact Information
First Name*
No Middle Name
- I Do Not Have a Middle Name
Middle Name*
Last Name*
Address*
Street Address Address Line 2 City State ZIP / Postal Code
Phone*
Student Email*

Please enter your MPTC student email.
Base Campus
Identification Information
The information below is requested by some clinical agencies in order to assign electronic health record access.
Birth Date
MM slash DD slash YYYY
Gender
Pronouns
Last 4 Digits of SSN*
Health & CPR Dates
Note: Copies of documents that verify completion of the COVID vaccine, most recent TB test, and a copy of the front and back of your most recent signed CPR card must be submitted to the Nursing Clinical Transition Coordinator prior to release of your placement assignment. (Submit requested documentation via email to Nicole Repp-Butzke at nrepp-butzke@morainepark.edu or fax to 920-907-6819 by date identified by Coordinator).
Most Recent Flu Vaccine
MM slash DD slash YYYY
Most Recent TB Test
MM slash DD slash YYYY
COVID Vaccine Dose 1
MM slash DD slash YYYY
COVID Vaccine Dose 2
MM slash DD slash YYYY
COVID Vaccine Booster
MM slash DD slash YYYY
CPR Expiration
MM slash DD slash YYYY
Current Employment
Are You Currently Employed?
- Yes
- No
Name of Current Employer
Location (City) of Current Employer
Current Employer Position (CNA, LPN etc)
Length of Time in Current Position (Years)
MPTC Nursing Program Clinical Course Placements and Semester and Year of Clinical
Fill in the name of the clinical agency, unit, and the semester and year of each clinical that you were enrolled in as part of the Associate Degree Nursing Program at MPTC.
Intro to Clinical Practice 543-104
Clinical Agency Unit Semester (Spring/Fall) and Year
Clinical Care Across the Lifespan 543-107
Clinical Agency Unit Semester (Spring/Fall) and Year
Intro to Clinical Care Management 543-108
Clinical Agency Unit Semester (Spring/Fall) and Year
Intermediate Clinical Practice 543-111*
Clinical Agency Unit Semester (Spring/Fall) and Year
Advanced Clinical Practice 543-115*
Clinical Agency Unit Semester (Spring/Fall) and Year
Nursing Clinical Transition Placement Preferences
Refer to the course orientation PowerPoint (sent to you by the Coordinator) which includes a list of possible clinical sites. List three possible choices below in order of preference.
Choice #1
Agency Name Department(s) Shift (1st, 2nd, 3rd) How is your learning supported by this placement
Choice #2
Agency Name Department(s) Shift (1st, 2nd, 3rd) How is your learning supported by this placement
Choice #3
Agency Name Department(s) Shift (1st, 2nd, 3rd) How is your learning supported by this placement
Factors Impacting on Placement Preference
What factors are most important to you in the determination of your clinical placement for Nursing Clinical Transitions? Read each item below and rate each in order of importance to you using 1 as most important, 2 as somewhat important, and 3 as not as important. Use each number only once.
Geographic Location of Facility
Type of Unit or Department within Facility
Shift
Other Comments
If you have other comments that you would like to share please include them in the box below.
Comments
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Nursing Clinical Transition Preceptor Request

Contact Information

Identification Information

Health & CPR Dates

Current Employment

MPTC Nursing Program Clinical Course Placements and Semester and Year of Clinical

Nursing Clinical Transition Placement Preferences

Factors Impacting on Placement Preference

Other Comments

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