Skip Sub Navigation Preceptor Portal Section Menu Preceptor Portal DNP Agency Liaison Checklist FNP Preceptor Guide Course Objectives PMHNP Preceptor Guide Course Objectives Student Evaluations Nursing Faculty Opens in a new window Do Not Edit: Do Not Edit: Do Not Edit: Don't Edit This Field: * = Required Fields Agency Liaison Information Agency Liaison First Name: * Agency Liaison Last Name: * Agency Liaison Organization (where you will supervise student): * Agency Liaison Email: * Student Information Student First Name: * Student Last Name: * Semester: * select... Spring Summer Fall Year * 2019 2020 2021 2022 2023 2024 2025 Course: * select... 701 702 703 704 Agency Liaison Requirements Please check each requirement that you meet (all requirements must be met to serve as an agency liaison). I am willing to serve as agency liaison for the above named student in the above named course, semester, and year. I am not related to or a friend of the student I will be supervising, and have no direct reporting relationship with them (e.g. supervisor). I understand orientation information on the roles of faculty, agency liaison, and student in a clinical learning experience will be emailed to me, and agree to read it. I understand course learning objectives will be emailed to me, and agree to read them. I understand I will be contacted a minimum of three times over the course of the semester, with an option to respond to the course faculty regarding concerns about student progress. I agree to fill out an end-of-course evaluation on the student’s performance and progress in the clinical learning experience. Optional I am interested and have the availability to work with another Gonzaga doctoral student for the above named semester Yes No Comments Agency Liaison Declaration I, the above named agency liaison, do attest by filling out and submitting this form I have read, understand, and meet the requirements indicated above to be an agency liaison for the student in the course named above. Agency Liaison Signature: * Submit Clear Form