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APRN Preceptor Profile Annual Update Form

Thank you for being a preceptor to nurse practitioner (NP) or clinical nurse specialist (CNS) student from the UVA School of Nursing! In order to comply with accreditation standards, the School must maintain records on preceptor profiles. Thank you in advance for updating your profile by submitting this form annually.

If you prefer to send an updated CV/resume instead of submitting this form, please send to jlo2n@virginia.edu.

Your name:

Your credentials:

Population-focused (and/or specialty, if applicable) area of practice

Type of certification

(for example: PNP-PC)

Certification organization
(for example: PNCB)

Date of certification expiration
(for example: 6/30/2025)

If you hold a second certification, please indicate:

Type of certification

(for example: PNP-AC)

Certification organization
(for example: PNCB)

Date of certification expiration
(for example: 6/30/2025)

Years of practice in the population-focused specialty area of practice:

Your current professional position/job:

Years in your current position:

Types of patients:

acute
chronic
in-hospital
other

Number of students precepted concurrently:

Education

Please provide your APRN program, specialty/population, institution, and year of graduation.

For example: MSN - PNP-PC, UVA, 2018.

License number and expiration date:

If you are an APRN, please upload a copy of your certification card/letter (for example, your FNP-BC certification letter). If you do not have a copy available at the moment, please email a scan or image of the letter to: jlo2n@virginia.edu at your convenience.

If you hold multiple APRN roles, please upload a copy of your additional certification card/letter here.

Thank you for your time and your contributions to the education of UVA nursing students! Please click the forward arrow below to submit your response.

This form adapted from the 2016 Criteria for Evaluation of Nurse Practitioner Programs, 5th ed. from NTF and NONPF.