MENNONITE COLLEGE OF NURSING
ILLINOIS STATE UNIVERSITY
Student Clinical Responsibilities Checklist
Student ______________________________________ Course: FNP I
FNP II
FNP III
FNP IV
NOTE: All forms mentioned below can be found at: http://my.ilstu.edu/~ddwilso2/Forms.htm
Preceptor #1 Information:
Name ________________________________________________________________________________
Facility _______________________________________________________________________________
Address ______________________________________________________________________________
Phone __________________________________ Email _______________________________________
Day/Times to be with preceptor __________________________________________________________
Preceptor #2 Information (if applicable):
Name ________________________________________________________________________________
Facility _______________________________________________________________________________
Address ______________________________________________________________________________
Phone __________________________________ Email _______________________________________
Day/Times to be with preceptor __________________________________________________________
Preceptor #3 Information (if applicable):
Name ________________________________________________________________________________
Facility _______________________________________________________________________________
Address ______________________________________________________________________________
Phone __________________________________ Email _______________________________________
Day/Times to be with preceptor __________________________________________________________
Activity
Date
Initial When
Completed
Done
Prior to Attending Clinical: (Note: See “Preceptor Planning Process” for deadlines for contracts.)
Turn in to Nanette Marx a completed “Preceptor Agreement Form”
for each preceptor to be used in the course. (For verification, either
have Nanette initial this form, or attach an email from her stating
she has received the form(s))
Verify with Nanette that a contract for the clinical facility is in place
and active. (NOTE: You are prohibited from attending clinical until
the contract is in place. No clinical hours will be accepted for sites
used which do not have a current contract in place.) (For
verification, either have Nanette initial this form, or attach an
email from her stating the contract(s) is/are in effect.)
Provide your preceptor with a copy of the “Preceptor Manual.”
For EACH Clinical Day:
Include an entry of your clinical hours on the “Clinical Preceptorship
Summary” form.
Complete the “Log of Patient Encounters”, including the cover sheet
(Note: This is to be turned in to your clinical instructor each week.)
Update the “Culminating Clinical Behaviors Checklist”
Update the “Visits Across the Lifespan Tally Sheet”
Throughout the Clinical Course:
Elicit feedback from your preceptor(s) regarding your performance
Develop goals for each clinical day and share these with your
preceptor…seek out experiences to expand your knowledge and
improve your performance
Complete 10 SOAP notes (to be completed and turned in to your
clinical instructor according to deadlines on course assignments
page)
 SOAP #1
 SOAP #2
 SOAP #3
 SOAP #4
 SOAP #5
 SOAP #6
 SOAP #7
 SOAP #8
 SOAP #9
 SOAP #10
Communicate with your clinical instructor via clinical log, email, or
phone if there are any concerns/problems with the clinical preceptor
or site (For example, if the preceptor is expecting you only to
observe, rather than be “hands on.”)
Coordinate with the clinical instructor to set a date for a clinical site
evaluation.
Prior to the site visit, provide the clinical instructor with complete
clinical site information (times in facility, directions, any special
information, such as parking, etc.)
At Midterm:
Have your preceptor sign the “midterm” line of the “Clinical
Preceptorship Summary,” verifying the hours completed thus far.
Prior to the End of Clinical Practicum
Provide your preceptor with a copy of the “Preceptor Evaluation of
Student” form to complete. This may either be mailed to Denise
Wilson at the College or given back to you for review/signature.
At the End of the Clinical
Have your preceptor sign the “final” line of the “Clinical
Preceptorship Summary,” verifying the hours completed.
Write your preceptor a thank you note. (Anything else, such as a gift
for the preceptor, etc., is optional.)
Complete the “Student Evaluation of Clinical Practicum and
Preceptor” form for each preceptor and site used.
Turn in to your clinical instructor all final required materials by the
deadline on the course assignments page. DO NOT turn in logs and
SOAPs again. Required materials include:
 Clinical Preceptorship Summary
 Clinical Site Visit and Evaluation by Course Faculty (to be
signed by clinical instructor and you)
 Preceptor Evaluation of Student from ALL preceptors used
for hands-on experiences (to be signed by clinical preceptor
and you)
 Student Evaluation of Clinical Practicum and Preceptor form
for ALL preceptors and clinical sites used.
 Culminating Clinical Behaviors Checklist (this will be returned
to you at the beginning of your next clinical so it can
continue to be used). Please ensure your name is on the
checklist.
 Visits Across the Lifespan Tally Sheet
5/12/2011; Updated 1/16/13