Consortium for Respiratory Care Education Preceptor Application

Name:

Credentials:

Address:

City:

State:

Zip Code:

Hospital /Facility:

State License Number:

Why do you want to become a Preceptor for the Respiratory Care Program?

Checklist for Application to the Preceptor Program:

Select All
Application with the Hospital Department Head’s signature
Preceptor Acknowledgment Form
Viewed the Interrater Reliability Video
Completed Competency Forms for Interrater Reliability Video (ABG Puncture & O2 Supply)