MSN FNP Preceptor Intent Submission
Anonymous Login Code:
Code Entry Page
Save this code which is required to update your response at a later time.
Student and Term Information
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What is your first and last name?
What is your Student ID number (starts with 850)?
What course number is this information for?
(NSGL 520 = Pediatric Health; NSGL 521 = Women's Health; NSGL 522 = Adult Primary Care I; NSGL 594 = Family Health Primary Care)
NSGL 520 Pediatric Health
NSGL 521 Women's Health
NSGL 522 Adult Health: Primary Care I
NSGL 594 Family Health: Primary Care II
What term will you be completing this rotation?
Fall 2019 - August 21, 2019 thru December 4, 2019
Spring 2020 - January 13, 2020 thru April 29, 2020
Fall 2020 - August 19, 2020 thru December 2, 2020
Spring 2021 - January 11, 2021 - April 28, 2021
What is your preceptor's First name?
Preceptor's Middle Initial/Name (Optional)
What is your preceptor's Last
What are your preceptor's credentials?
Other, please specify
Agency Contact full name and title:
This is either a practice manager, executive assistant, secretary, etc. that communicates information directly to your preceptor. If you have provided direct contact information for your preceptor, this can be skipped.
This is extremely important as we will communicate paperwork, rotation requirements, and so on directly with your preceptor or their contact person via email. If you would like to provide multiple emails, please separate emails with a semicolon(;).
Agency Phone Number:
Agency Full Name
Street address 2 (if applicable):
What AHEC Region does this rotation fall in? This depends on the county the rotation is taking place in. Please use this link to assist you in answering:
Area L AHEC (Edgecombe, Halifax, Nash, Northampton, Wilson)
Charlotte AHEC (Anson, Cabarrus, Cleveland, Gaston, Lincoln, Mecklenburg, Stanly, Union)
Eastern AHEC (Beaufort, Bertie, Camden, Carteret, Chowan, Craven, Currituck, Dare, Gates, Greene, Hertford, Hyde, Jones, Lenoir, Martin, Onslow, Pamlico, Pasquotank, Perquimans, Pitt, Tyrrell, Washington, Wayne)
Greensboro AHEC (Alamance, Caswell, Guilford, Montgomery, Randolph, Rockingham)
Mountain AHEC (Buncombe, Cherokee, Clay, Graham, Haywood, Henderson, Jackson, Macon, Madison, McDowell, Mitchell, Polk, Rutherford, Swain, Transylvania, Yancey)
Northwest AHEC (Alexander, Alleghany, Ashe, Avery, Burke, Caldwell, Catawba, Davidson, Davie, Forsyth, Iredell, Rowan, Stokes, Surry, Watauga, Wilkes, Yadkin)
South East AHEC (Brunswick, Columbus, Duplin, New Hanover, Pender)
Southern Regional AHEC (Bladen, Cumberland, Harnett, Hoke, Moore, Robeson, Richmond, Sampson, Scotland
Wake AHEC (Franklin, Granville, Johnston, Lee, Vance, Wake, Warren)
Please fill in your preceptor's RN or medical license number.
How many total hours do you plan to complete with this preceptor within this term?
If you are going to have multiple preceptors within the same semester, please SUBMIT A NEW SURVEY for that preceptor and allot the hours accordingly.
Are you currently employed by this agency?
Is this site you are submitting a part of Atrium Health?
If you select
, there are fees and
associated with being placed at an Atrium Health site. Starting in the SPRING 2019 semester, students that select an Atrium Health site to do their rotation
will be required to pay
the associated fees.
*If you are unsure if your site is an Atrium site, visit their
and click their Locations tab to search your site.
If you are unsure if your site is an Atrium site, visit their https://atriumhealth.org/ and click their Locations tab to search your site.
If you would like your results emailed to you, please provide your UNCW email below using the @uncw.edu (i.e.