Preceptor Form

Northeast Region Wound Ostomy Continence Nurses Society

New York, New Jersey, Pennsylvania

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Wound Ostomy and Continence Nurses Society

 

Northeast Region WOC Nursing Education Program

Preceptor Information

 

General Requirements:  (May vary depending on program)

 

-          Baccalaureate degree with a major in nursing, or RN with baccalaureate degree in a discipline other than nursing (competencies in health assessment, community health nursing, leadership and management and research and statistics must be documented)

-          Graduate of a WOCN accredited nursing education program

-          At least 1 year of full time clinical experience after graduating from an accredited WOC nursing education program

-          Current certification

-          Documented caseload

 

 

Name                     :

 

Credentials             :

 

Facility                   :

 

Address of facility    :

              

Phone                    :

 

e-mail                    :

 

 Setting

Acute Care             :

Long Term Care      :

Home Care             :

Outpatient              :

 

Practice

Wound                   :

Ostomy                  :

Continence             :

 

 

 I agree to the above information being provided to the WOCN accredited

Wound, Ostomy and Continence Nursing Education Programs.

 

                                                   

        Signature                                                                        Date

 

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Last updated: 02/20/08.