Preceptor or Clinical Mentor Information Form - Copy

Intro.Txt PRECEPTOR/CLINICAL MENTOR INFORMATION AND CONTRACT FORM

Intro.1 Thank you very much for agreeing to precept or mentor a University of Toledo College of

Nursing student. If this is your first time completing the on-line version of the contract

information form, you must complete all sections before submitting the form. The

Preceptor/Clinical Mentor Information and Contract Form can ONLY be completed and

submitted on-line. We will not accept copied, handwritten, or previous versions of this

document. If you have completed the on-line version of this form previously, please carefully

review SECTIONS I – IX for accuracy and make any necessary changes, then fully then

complete SECTION X. We recommend the first time you complete this form that you do not use

a small mobile device, such as a cell phone, since some sections may not fit the viewing

screen. Please ensure you are using the Internet browser Mozilla Firefox to complete this

survey.

Q1.1 SECTION I OHIO ADMINISTRATIVE CODE (OAC) RULES Please read these rules and

click on the statement below the rules indicating that you have read them. Rule 4723-5-

10(A)(5), OAC, specifies that a Preceptor for an RN nursing education program shall have (a)

completed an approved registered nursing education program; (b) have experience for at least

two years in the practice of nursing as an RN with demonstrated competence in the area of

clinical practice in which the Preceptor provides supervision to a nursing student; (c) have a

current, valid license as an RN. A BSN is preferred. Rule 4723-5-20(F), OAC, specifies that

the teaching assistant or Preceptor providing supervision of a nursing student shall at least: (1)

Have competence in the area of clinical practice in which the teaching assistance or Preceptor

is providing supervision to a student; (2) Design, at the direction of a faculty member, the

student’s experience to achieve the stated objectives or outcomes of the nursing course in

which the student is enrolled; (3) Clarify with the faculty member; (a) The role of the

teaching assistant or Preceptor; (b) The responsibilities of the faculty

member; (c) The course and clinical objectives or outcomes; (d) The clinical

experience evaluation tool; and (4) Contribute to the evaluation of the student’s performance by

providing information to the faculty member and the student regarding the student’s

achievement of established objectives or outcomes. Rule 4723-5-20(G), OAC, specifies that a

Preceptor shall provide supervision to no more than two nursing students at any one time,

provided the circumstances are such that the Preceptor can adequately supervise the practice

of both students.

I have read the above Ohio Administrative Code (OAC) Rules (1)

Q2.Txt SECTION II DEMOGRAPHIC INFORMATION

Q2.1 2.1. Please check over the following information about yourself. Please correct anything

that is incorrect and fill in any blanks.

Suffix: Mr, Mrs, Ms, or Dr. (1)

First Name (2)

Last Name (3)

Home Address (4)

City (5)

State (Two letter abbreviation) (6)

Zip Code (7)

Home Phone Number (XXX-XXX-XXXX) (8)

Cell Phone Number (XXX-XXX-XXXX) (9)

Personal E-mail Address (Home) (10)

Q3.Txt SECTION III EDUCATION INFORMATION

Q3.1 3.1. Please select which of the following degree(s) you were awarded from the list

below. Please include any programs in which you are currently enrolled. Please select ALL

THAT APPLY.

LPN (Licensed Practical Nurse) (1)

Diploma Nurse (2)

ADN (Associate Degree Nurse) (3)

BSN (Baccalaureate Nurse) (4)

MSN (Master Nurse) (5)

CNL (Clinical Nurse Leader) (6)

APN (Advanced Practice Nurse) (7)

CNS (Clinical Nurse Specialist) (8)

DNP (Doctorate of Nursing Practice) (9)

MD (Medical Doctor) (10)

DO (Doctor of Osteopathy) (11)

PhD (12)

Other Degree 1 (13)

Other Degree 2 (14)

Answer If 3.1. Please select which of the following degree(s) you were awarded from the list

below. Please include any programs in which you are currently enrolled. Please select ALL

THAT APPLY. PhD Is Selected Or 3.1. Please select which of the following degree(s) you

were awarded from the list below. Please include any programs in which you are currently

enrolled. Please select ALL THAT APPLY. Other Degree 1 Is Selected Or 3.1. Please select

which of the following degree(s) you were awarded from the list below. Please include any

programs in which you are currently enrolled. Please select ALL THAT APPLY. Other Degree

2 Is Selected

Q3.1a 3.1a. Please provide additional detail about the degrees you selected in the prior

question.

If 3.1. Please select which of the following degree(s) you were awarded from the list

below. Please include any programs in which you are currently enrolled. Please select ALL

THAT APPLY. PhD Is Selected

PhD (Please Define) (1) ____________________

If 3.1. Please select which of the following degree(s) you were awarded from the list

below. Please include any programs in which you are currently enrolled. Please select ALL

THAT APPLY. Other Degree 1 Is Selected

Other Degree 1 (Please Define) (2) ____________________

If 3.1. Please select which of the following degree(s) you were awarded from the list

below. Please include any programs in which you are currently enrolled. Please select ALL

THAT APPLY. Other Degree 2 Is Selected

Other Degree 2 (Please Define) (3) ____________________

Q3.2 3.2. Please list the school/college/university, the month and year of graduation, and the

years in clinical practice (if applicable) for the degrees you selected above. If you are currently

in a program of study, please select your expected month and year of graduation. Please scroll

to the right ⇒ if you do not see all 4 columns on your screen viewer.

Q4.Txt SECTION IV LICENSE INFORMATION The University of Toledo College of Nursing is

required to maintain current documentation of license information and verifies the license of

each Preceptor or Clinical Mentor.

Q4.1 4.1. License Information Please provide the following required information about your

current license.

License Number (1)

State License was Issued (two letter abbreviation) (2)

Expiration Date (mm/dd/yyyy) (3)

Q4.2 4.2. Do you hold an out of state license?

Yes (1)

No (2)

Answer If 1a) Do you hold an out of state license? Yes Is Selected

Q4.2a 4.2a. Out of State License Information Please provide the following information about

your out of state license.

License Number (1)

State License was Issued (two letter abbreviation) (2)

Expiration Date (mm/dd/yyyy) (3)

Q5.Txt SECTION V CERTIFICATION INFORMATION

Q5.1 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple specialties.

Advanced Life Support (1)

Adult/Family Health Nursing (2)

Advice/Call Nursing (3)

Case Management Nursing (4)

Community Health Nursing (5)

Critical Care/Cardiovascular Nursing (6)

Dermatology Nursing (7)

Diabetes Education (8)

Emergency Nursing (9)

Forensic Nursing (10)

Gastroenterology Nursing (11)

Gerontology Nursing (12)

Home Health Nursing (13)

Hospice Nursing (14)

Infusion Nursing (15)

Informatics Nursing (16)

Intermediate Care Nursing (17)

Lactation Nursing (18)

Leadership/Management (19)

Legal Nursing (20)

Medical-Surgical Nursing (21)

Nephrology Nursing (22)

Neuroscience Nursing (23)

Oncology Nursing (24)

Orthopedic Nursing (25)

Pediatric Nursing (26)

Peri-Operative Nursing (27)

Professional Development (28)

Psychiatric and Mental Health Nursing (29)

Public Health (30)

Radiological Nursing (31)

Rehabilitation Nursing (32)

School Nursing (33)

Urologic Nursing (34)

Women's Health Nursing (35)

Wound, Ostomy, Continence Nursing (36)

Other (37)

Answer If What is your current area of specialty practice?  Please select all that apply by

holding down the Control key and selecting multiple specialties. Other Is Selected

Q5.1a 5.1a. Please provide more detail about the "Other" specialty you selected in the prior

question.

Q5.2 5.2. Do you hold any nursing certifications in your current area(s) of specialty practice?

Yes (1)

No (2)

If No Is Selected, Then Skip To End of Block

Q5.3 5.3. Please select which of the following certifications you hold in each of your areas of

specialty.

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Advanced Life Support Is Selected Advanced Life Support

(x1)

Advanced Cardiac Life

Support (ACLS) (1)

Pediatric Advanced Life

Support (PALS) (2)

None (3) (4) (5) (6) (7)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Adult/Family Health Nursing Is

Selected Adult/Family Health

Nursing (x2)

Adult Nurse Practitioner (APN) (1)

Adult Nurse Practitioner Board

Certified (APN-BC) (2)

Family Nurse Practitioner

Board Certified

(FNP-BC) (3)

Family Nurse Practitioner (FNP) (4)

Acute Care Nurse

Practitioner Board Certified (ACNP-BC) (5)

Adult Health CNS

Board Certified

(ACSN-BC) (6)

None (7)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Advice/Call Nursing Is Selected

Advice/Call Nursing (x3)

Ambulatory Care Nurse (ACN) (1)

None (2) (3) (4) (5) (6) (7)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple specialties. Case

Management Nursing Is Selected

Case Management Nursing (x4)

Nursing Case Management

(NCM) (1) None (2) (3) (4) (5) (6) (7)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Community Health Nursing Is

Selected Community Health

Nursing (x5)

Community Health

Nursing (CHN) (1)

Home Health Nursing (HHN) (2)

Home Health CNS

(HHCNS) (3)

Faith Community

Nursing (AFCN) (4)

None (5) (6) (7)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Critical Care/Cardiovascular Nursing Is Selected

Critical Care/Cardiovascular

Nursing (x6)

Certified Critical Care

Nurse (CCRN) (1)

Critical Care CNS (CCNS) (2)

Cardiac Vascular

Nurse (CVN) (3)

Cardiac Surgery Sub-specialty Certification (CSC) (4)

Cardiac Medicine

Sub-specialty

Certification (CMC)

(5)

Progressive Care

Nursing Certification (PCCN) (6)

None (7)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Dermatology Nursing Is Selected

Dermatology Nursing (x7)

Dermatology Nurse

Certified (DNC) (1)

None (2) (3) (4) (5) (6) (7)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Diabetes Education Is Selected

Diabetes Education (x8)

Certified Diabetes Educator (CDE) (1)

Diabetes Management

Nurse (DMN) (2)

Diabetes Management

Advanced (DMA) (3)

None (4) (5) (6) (7)

If 5.1. What is your current area of specialty practice? Please select

Certified Emergency

Nurse (CEN)

Certified Flight Registered Nurse

(CFRN) (2)

Emergency Nurse

Practitioner None (4) (5) (6) (7)

ALL THAT APPLY by holding down the "Control" key and selecting multiple

specialties. Emergency Nursing Is Selected

Emergency Nursing (x9)

(1) (ENP) (3)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Forensic Nursing Is Selected

Forensic Nursing (x10)

Certified Forensic

Nursing (CFN) (1)

SANE-A (2) SANE-P (3) SANE-P/A (4) None (5) (6) (7)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Gastroenterology

Nursing Is Selected Gastroenterology

Nursing (x11)

Certified Gastroenterol

ogy Nurse (CGRN) (1)

None (2) (3) (4) (5) (6) (7)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Gerontology Nursing Is Selected Gerontology Nursing

(x12)

Gerontological Nurse

Certified (GNC) (1)

Adult-Gerontology

Primary Care NP (AGNP) (2)

Gerontological Nurse

Practitioner Board

Certified (GNP) (3)

Gerontological CNS Board

Certified (GCNS) (4)

None (5) (6) (7)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Home Health Nursing Is Selected

Home Health Nurse

Certification (HHNC) (1)

None (2) (3) (4) (5) (6) (7)

Home Health Nursing (x13)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Hospice Nursing Is Selected

Hospice Nursing (x14)

Certified Hospice and

Palliative (CHPN) (1)

Advanced Certified Hospice

and Palliative Nurse (ACHPN)

(2)

Pain Management Nurse (RN-

BC) (3)

None (4) (5) (6) (7)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Infusion Nursing Is Selected

Infusion Nursing (x15)

Vascular Access- Board

Certified (VA-BC) (1)

Certified Registered Nurse Infusion (CRNI)

(2)

None (3) (4) (5) (6) (7)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Informatics Nursing Is Selected Informatics Nursing

(x16)

Informatics Nursing (RN-

BC) (1) None (2) (3) (4) (5) (6) (7)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Intermediate Care Nursing Is

Selected Intermediate Care

Nursing (x17)

Progressive Care Certified Nurse (PCCN)

(1)

None (2) (3) (4) (5) (6) (7)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

Certified Lactation

Consultant (IBCLC) (1)

None (2) (3) (4) (5) (6) (7)

holding down the "Control" key and selecting multiple

specialties. Lactation Nursing Is Selected

Lactation Nursing (x18)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Leadership/Management

Is Selected Leadership/Management

(x19)

Certified Nurse

Manager and Leader

(CNML) (1)

Nurse Executive Board Certified

(NE-BC) (2)

Nurse Executive Advanced

Board Certified (NEA) (3)

None (4) (5) (6) (7)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple specialties. Legal

Nursing Is Selected Legal Nursing (x20)

Legal Nurse Consultant Certification (LNCC) (1)

None (2) (3) (4) (5) (6) (7)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Medical-Surgical Nursing Is

Selected Medical-Surgical

Nursing (x21)

Certified Medical Surgical

Registered Nurse

(CMSRN) (1)

None (2) (3) (4) (5) (6) (7)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Nephrology Nursing Is Selected

Certified Hemodialysis Nurse (CHN)

(1)

Certified Peritoneal

Dialysis Nurse (CPN) (2)

Certified Nephrology

Nurse (CNN) (3)

None (4) (5) (6) (7)

Nephrology Nursing (x22)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Neuroscience Nursing Is

Selected Neuroscience Nursing

(x23)

Certified Neuroscience

Registered Nurse

(CNRN) (1)

None (2) (3) (4) (5) (6) (7)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Oncology Nursing Is Selected

Oncology Nursing (x24)

Oncology Certified

Nurse (OCN) (1)

Certified Pediatric Oncology (CPON)

(2)

Certified Breast Care

Nurse (CBCN) (3)

Advanced Oncology

Certified Nurse Practitioner

(AOCNP) (4)

Advanced Oncology

CNS (AOCNS)

(5)

None (6) (7)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Orthopedic Nursing Is Selected Orthopedic Nursing

(x25)

Orthopedic Nurse

Certified (ONC) (1)

Orthopaedic Nurse Practitioner

(ONP) (2)

Orthopaedic CNS (OCNS)

(3) None (4) (5) (6) (7)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Pediatric Nursing Is Selected

Pediatric Nursing (x26)

Certified Neonatal

Intensive Care Nurse (RNC-

NIC) (1)

Pediatric Nursing (PN) (2)

Pediatric CNS (PCNS) (3)

Pediatric Primary Care NP (PNP) (4)

None (5) (6) (7)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

Certified Registered

Nurse Anesthetist

Certified Nursing Operating Room

(CNOR) (2)

Certified Post Anesthesia Registered

Nurse (CPAN)

Certified RN First Assistant (CRNFA) (4)

Certified Ambulator

y Perianesth

None (6) (7)

holding down the "Control" key and selecting multiple specialties. Peri-

Operative Nursing Is Selected

Peri-Operative Nursing (x27)

(CRNA) (1) (3) esia Nurse (CAPA) (5)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Professional Development Is

Selected Professional

Development (x28)

Nursing Professional Development

(NPD) (1)

None (2) (3) (4) (5) (6) (7)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Psychiatric and Mental Health

Nursing Is Selected Psychiatric and Mental Health Nursing (x29)

Psychiatric Mental Health

Nurse (PMHN) (1)

Adult Psychiatric and Mental

Health Nurse Practitioner Board

Certified (PMHNP) (2)

Adult Psychiatric–

Mental Health CNS

(PMHCNS-BC) (3)

Child/Adolescent Psychiatric–

Mental Health CNS (PMHCNS-

BC) (4)

None (5) (6) (7)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple specialties. Public Health Is Selected Public Health (x30)

Public Health Nursing

(PHN) (1)

Public/Community Health CNS (PHCNS) (2)

Advanced Public Health Nursing Board

Certified (APHN) (3)

None (4) (5) (6) (7)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

Certified Radiological Nurse (CRN)

(1)

None (2) (3) (4) (5) (6) (7)

specialties. Radiological Nursing Is Selected Radiological Nursing

(x31)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Rehabilitation Nursing Is

Selected Rehabilitation Nursing

(x32)

Certified Rehabilitation

Registered Nurse

(CRRN) (1)

Cardiac Rehabilitation

Nursing (CRN) (2) None (3) (4) (5) (6) (7)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. School Nursing Is Selected

School Nursing (x33)

National Certified

School Nurse (NCSN) (1)

School Nurse Practitioner (SNP)

(2) None (3) (4) (5) (6) (7)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Urologic Nursing Is Selected

Urologic Nursing (x34)

Certified Urologic Certified Nurse

(CURN) (1)

None (2) (3) (4) (5) (6) (7)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Women's Health Nursing Is

Selected Women's Health Nursing

(x35)

Certified Inpatient

Obstetrics Nurse (RNC-

OB) (1)

High-Risk Perinatal Nursing

(2)

Maternal Newborn

Nurse (RNC-MNN) (3)

Inpatient Obstetric Nurse (RNC-OB) (4)

Certified Nurse

Midwife (CNM) (5)

None (6) (7)

If 5.1. What is your Certified Certified Wound Certified Certified Ostomy Certified None (6) (7)

current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Wound, Ostomy, Continence Nursing Is Selected

Wound, Ostomy, Continence Nursing

(x36)

Wound, Ostomy,

Continence Nurse

(CWOCN) (1)

Ostomy Nurse (CWON) (2)

Wound Care Nurse

(CWCN) (3)

Care Nurse (COCN) (4)

Continence Care Nursing (CCCN)

(5)

If 5.1. What is your current area of specialty practice? Please select ALL THAT APPLY by

holding down the "Control" key and selecting multiple

specialties. Other Is Selected

Other (x37)

Other (1) (2) (3) (4) (5) (6) (7)

Answer If 5.3. Please select which of the following certifications you hold in each of your areas

of specialty. Other - Other Is Selected

Q5.3a 5.3a. Please provide more detail about the "Other" certification you selected in the prior

question.

Q5.4 5.4. Please select the month and year of your renewal date and the granting certification

organization for the certification(s) selected in the previous question.

Renewal Month Renewal Year Granting Certification Organization

January (1)

February (2)

March (3)

April (4)

May (5)

June (6)

July (7)

August (8)

September (9)

October (10)

November (11)

December (12)

Not

Applicable (13)

2012 (1)

2013 (2)

2014 (3)

2015 (4)

2016 (5)

2017 (6)

2018 (7)

2019 (8)

2020 (9)

2021 (10)

2022 (11)

2023 (12)

2024 (13)

2025 (14)

2026 (15)

2027 (16)

2028 (17)

2029 (18)

2030 (19)

Not

Applicable (20)

American Nurse Credentialing

Center (1)

Academy of Medical-Surgical

Nurses Certification

Board (2)

American

Academy of

Nurse Practitioners

Certification

Program (3)

American Association of

Critical Care

Nurses (4)

American Association of

Neuroscienc

e Nurses (5)

American

Board of Perianesthesia

Nursing

Certification (6)

American Heart Association (7)

American Legal

Nurse Consultan

t Certification

Board (8)

American Midwifery Certification

Board (9)

Association for Vascular Access

(10)

Board of

Certification

for Emergenc

y Nursing

(11)

Board of Nephrology Examiners

Nursing & Technology (12)

Certifying Board of

Gastroenterolo

gy Nurses

(13)

Competency &

Credentialing

Institute (14)

Dermatology

Nurses' Association

(15)

Infusion

Nurses Certification

Corporation

(16)

International Board of

Lactation Consultan

t Examiners (17)

National Board for Certification of Hospice &

Palliative Nurses (18)

National Board of

Certification of Schoo

l Nurses (19)

National

Certification

Board for Diabetes Ed (20)

National Board of

Certification

and Re-certification of Nurse Anesthetists (21

)

National

Certification

Corporation

(22)

Oncology Nursing

Certification

Corporation

(23)

Orthopedic

Nurses Certification

Board (24)

Society of Urologic

Nursing

Association (25

)

Wound Ostomy

Continence

Nursing

Certification

Board (26)

Other (27)

Not

Applicable (28)

Advanced Cardi

ac Life

Support

(ACLS) (1)

Pediatric

Advanced Life

Support

(PALS) (9)

Adult Nurs

e Practi

tioner (APN) (10)

Adult Nurs

e Practitioner Boar

d Certified

(APN-BC) (11)

Family

Nurse

Practitioner Boar

d Certified

(FNP-BC) (12)

Family

Nurse

Practitioner (FNP) (13)

Acute Care Nurs

e Practitioner Boar

d Certified

(ACNP-

BC)

(14)

Adult Healt

h CNS Boar

d Certified

(ACSN-

BC) (15)

Ambulator

y Care Nurs

e (ACN) (19)

Nursing

Case Manageme

nt (NCM)

(20)

Communit

y Healt

h Nursi

ng (CHN) (21)

Home

Health

Nursing

(HHN) (22)

Hom

e Healt

h CNS (HHCNS) (23)

Faith Communit

y Nursi

ng (AFC

N) (32)

Certified

Critical

Care Nurs

e (CCR

N) (33)

Critical

Care CNS (CCN

S) (34)

Cardiac

Vascular Nurs

e (CVN) (35)

Cardiac

Surgery

Sub-specialty

Certif

ication

(CSC) (36)

Cardiac

Medicine Sub-specialty

Certificatio

n (CMC)

(37)

Progressiv

e Care Nursi

ng Certificatio

n (PCC

N) (38)

Dermatolo

gy Nurs

e Certified

(DNC) (39)

Certified

Diabetes Educator

(CDE) (40)

Diabetes

Mana

gement

Nurse

(DMN)

(41)

Diabetes

Manageme

nt Advanced (DMA) (42)

Certified

Emergenc

y Nurs

e (CEN) (43)

Certified

Flight Registered Nurs

e (CFR

N) (44)

Emergenc

y Nurs

e Practitioner (ENP) (45)

Certified

Forensic Nursi

ng (CFN) (46)

SANE-A (47)

SANE-P (48)

SANE-

P/A (49)

Certified

Gastroenterolog

y Nurs

e (CGR

N) (50)

Gerontological Nurs

e Certified

(GNC) (51)

Adult-

Gerontolo

gy Primary

Care NP

(AGNP)

(52)

Gerontological

Nurse

Practitioner Boar

d Certified

(GNP) (53)

Gerontological CNS Boar

d Certified

(GCNS)

(54)

Home

Health

Nurse

Certificatio

n (HHN

C) (55)

Certified

Hospice

and Palliative

(CHPN)

(56)

Advanced Certified

Hospice

and Palliative Nurs

e (ACHPN) (57)

Pain Manageme

nt Nurs

e (RN-BC) (58)

Vascular Access-

Board

Certified

(VA-BC) (59)

Certified

Registered Nurs

e Infusi

on (CRN

I) (60)

Informatic

s Nursi

ng (RN-BC) (61)

Progressiv

e Care Certified

Nurse

(PCCN)

(62)

Certified

Lactation

Consultant (IBCL

C) (63)

Certified

Nurse

Manager and Lead

er (CNML) (64)

Nurse

Executive Boar

d Certified

(NE-BC) (65)

Nurse

Executive Advanced Boar

d

Certified

(NEA) (66)

Legal Nurs

e Consultant Certificatio

n (LNC

C) (67)

Certified

Medical

Surgical

Registered Nurs

e (CMSRN) (68)

Certified

Hemodialysis Nurs

e (CHN) (69)

Certified

Peritoneal Dialysis

Nurse

(CPN) (70)

Certified

Nephrolog

y Nurs

e (CNN) (71)

Certified

Neuroscience

Registered Nurs

e (CNR

N) (72)

Oncology

Certified

Nurse

(OCN) (73)

Certified

Pediatric

Oncology

(CPON)

(74)

Certified

Breast

Care Nurs

e (CBC

N) (75)

Advanced Onco

logy Certified

Nurse

Practitioner (AOCNP) (76)

Advanced Oncology CNS (AOCNS) (77)

Orthopedic Nurs

e Certified

(ONC) (78)

Orthopaedi

c Nurs

e Practitioner (ONP) (79)

Orthopaedi

c CNS (OCN

S) (80)

Certified

Neonatal

Intensive Care

Nurse

(RNC-

NIC) (81)

Pediatric

Nursing

(PN) (82)

Pediatric

CNS (PCN

S) (83)

Pediatric

Primary

Care NP

(PNP) (84)

Certified

Registered Nurs

e Anesthetist (CRN

A) (85)

Certified

Nursing

Operating Room

(CNOR)

(86)

Certified

Post Anesthesia Registered Nurs

e (CPA

N) (87)

Certified RN First Assistant

(CRNFA) (88)

Certified

Ambulator

y Perianesthesia Nurs

e (CAP

A) (89)

Nursing

Profession

al Developme

nt (NPD) (90)

Psychiatri

c Ment

al

Health

Nurse

(PMHN)

(91)

Adult Psychiatric and Ment

al Healt

h Nurs

e Practitioner Boar

d Certified

(PMHNP) (92)

Adult Psychiatri

c–Ment

al Healt

h CNS (PMHCNS-BC) (93)

Child/Adolescent Psychiatri

c–Ment

al Healt

h

CNS (PMHCNS-BC) (94)

Public

Health

Nursing

(PHN) (95)

Public/Community

Health

CNS (PHCNS) (96)

Advanced Publi

c Healt

h Nursi

ng Boar

d Certified

(APHN)

(97)

Certified

Radiological

Nurse

(CRN) (98)

Certified

Rehabilitati

on Registered Nurs

e (CRR

N) (99)

Cardiac

Rehabilitati

on Nursi

ng (CRN

) (100)

National

Certified

School

Nurse

(NCSN)

(101)

School

Nurse

Practitioner (SNP

) (102)

Certified

Urologic

Certified

Nurse

(CUR

N) (103)

Certified

Inpatient

Obstetrics Nurs

e (RNC- OB) (104)

High-Risk Perinatal

Nursing

(105)

Maternal

Newborn

Nurse

(RNC-

MNN)

(106)

Inpatient

Obstetric Nurs

e (RNC-OB) (107)

Certified

Nurse

Midwife

(CNM)

(108)

Certified

Wound,

Ostomy,

Continenc

e Nurs

e (CW

OCN) (109)

Certified

Wound

Ostomy

Nurse

(CWON) (110)

Certified

Wound

Care Nurs

e (CWCN) (111)

Certified

Ostomy

Care Nurs

e (COC

N) (112)

Certified

Continenc

e Care Nursi

ng (CCC

N) (113)

Other (8)

Answer If 5.3. Please select which of the following certifications you hold in each of your areas

of specialty. Adult/Family Health Nursing - Adult Nurse Practitioner (APN) Is Selected Or 5.3.

Please select which of the following certifications you hold in each of your areas of

specialty. Adult/Family Health Nursing - Adult Nurse Practitioner Board Certified (APN-BC) Is

Selected Or 5.3. Please select which of the following certifications you hold in each of your

areas of specialty. Adult/Family Health Nursing - Family Nurse Practitioner Board Certified

(FNP-BC) Is Selected Or 5.3. Please select which of the following certifications you hold in each

of your areas of specialty. Adult/Family Health Nursing - Family Nurse Practitioner (FNP) Is

Selected Or 5.3. Please select which of the following certifications you hold in each of your

areas of specialty. Adult/Family Health Nursing - Acute Care Nurse Practitioner Board Certified

(ACNP-BC) Is Selected

Q5.4a 5.4a. Please provide the following information about your Advanced Practice Nurse

credentials.

Schedule A Certificate of Authority Expiration Date (mm/dd/yyyy) (1)

Schedule II Continuing Nursing Education Date (mm/dd/yyyy) (2)

Q6.Txt SECTION VI EMPLOYMENT INFORMATION

Q6.1 6.1. Please provide the following information about your current employer.

Primary Current Employer (1)

Address (2)

City (3)

State (two letter abbreviation) (4)

Zip Code (5)

Phone Number where we can reach you at work (XXX-XXX-XXXX) (6)

Your work E-mail Address (7)

Department/Unit Name (8)

Name of Immediate Supervisor/Manager (if applicable) (9)

Phone Number of Immediate Supervisor/Manager (XXX-XXX-XXXX) (10)

E-mail of Immediate Supervisor/Manager (11)

Fax Number (12)

Q7.Txt SECTION VII CLINICAL LOCATION INFORMATION

Q7.1 7.1. Please select the clinical location where you will be precepting students from the list

below. Please examine all options for your clinical location before selecting your response. If

you don't see your clinical location in the list, please select "CLINICAL LOCATION IS NOT IN

LIST" at the bottom of the drop down list. If you have more than one clinical location where you

will be precepting students, please select for this question the location where you will precept

the greatest number of students. You will be asked for information on your other clinical

location(s) in subsequent questions.

Ability Center of Greater Toledo, The (13)

Adolecent & Young Adult Health Services (14)

Advanced Neurologic Assoc., Inc. (15)

Advanced Specialty Hospital (16)

AHEC (Huron, OH) (17)

AHEC (Toledo, OH) (18)

AHEC (OB/GYN) (19)

Airport Pediatrics (20)

Airport Urgent Care (21)

Alexis Medical Center (22)

All About Women (23)

Allegiance Health (24)

Allen County Health Department (25)

Allen County Health Partners (26)

Alliance for Women's Health (27)

Alliance Health Emergency (28)

American Health Network of Ohio PC (29)

Anne Grady Day Program (30)

Anthony Wayne Schools (31)

APRN Health Care Providers (32)

Area Office on Aging Northwest Ohio (33)

Arrowhead Behavioral Healthcare (34)

Arrowhead Family Physicians (35)

Arthur-Menasch MD (36)

AseraCare Hospice (37)

Associates in Women's Health (38)

Asthma and Allergy Care Center (39)

Autism Model School, The (40)

Baldwin Wallace University (41)

Barnett, Robert M.D (42)

Baton Rouge Health Services (43)

Batton Rouge Senior Health Services (44)

Bay Park Family Practice (45)

Bay Park Hospital (46)

Bay Park Hospital Emergency Department (47)

Bay Park Internal Medicine (48)

Bay Park Women's Health (49)

Bay Park Women's Services (50)

Bayshore OB/GYN (51)

Bayside Women's Center (52)

Beach House, The (54)

Beach, Patricia (CNS-Pallative Care) (55)

Beasley, Gary R. DO (56)

Bedford Family Physicians (57)

Behavioral Connections of Wood County (58)

Bellevue City Schools (59)

Bellevue Hospital (60)

Bellevue Professional Services (61)

Bixby Hospital and Emergency Department (62)

Black, Marianne (63)

Blanchard Family Physicians (64)

Blanchard Valley Health System (Hem/Onc Internal Medicine) (65)

Blanchard Valley Health System: (66)

Blanchard Valley Hospital (67)

Blanchard Valley Medical Associates (68)

Blanchard Valley Medical Association (69)

Blanchard Valley Regional Health Center (70)

Blanchard Valley Surgical Specialists (71)

Blanchard Valley Women's Care (72)

Blissfield Family Care (73)

Bluffton Physicians, Inc. (74)

Bluffton Women's Care (75)

BMC&EMC (76)

Bodie, David MD (77)

Borgess Center for Diabetes Care (78)

Bowes, Robert (OB/GYN) (79)

Bowling Green City Schools (80)

Bowling Green Clinic (81)

Bowling Green Family Care Center (82)

Bowling Green Family Physicians (83)

Bowling Green Student Health Services (84)

Boyce, Vanessa K. (85)

Boys & Girls Club of Toledo (86)

Branch Hillsdale St. Joseph Community Health Agency (87)

Bronson Lakeview Family Care (Decatur, MI) (89)

Bronson Lakeview Family Care (Paw Paw, MI) (90)

Bryan City School District (91)

C & C Health Services (92)

Camp Courageous, Inc. (93)

CardioCare Consultants (94)

Cardiology Care Assoc.Inc. (95)

Cardiology Wellness of Toledo (96)

Caughman Clinic - BVRHC (97)

Caughman Health Center (98)

Center for Child Development (99)

Center for Family Health (Jackson, MI) (100)

Center for Family Health (Toledo, OH) (101)

Center for Health Services Medicine Clinic (102)

Center for Pulmonary Medicine (103)

Central Catholic High School (104)

Central Park Pediatrics (105)

Chartier Family Medicine (106)

CHCI (107)

Cherry Street Mission (108)

Childrens Hopsital Columbus (109)

Children's Hospital Medical Center of Akron (110)

Children's Intensive Caring (111)

Clark and Kasper Inc. (112)

Clark County Combined Health District (113)

Clay-Hufford, Susan, M.D. (114)

Cleveland Clinic (115)

Cleveland Clinic Foundation, The (116)

Cleveland Clinic Loraine Family Health Center (117)

Clyde Health Clinic, The (118)

Clyde-Green Springs Schools (119)

Cockley, Mark, MD Mark Cockley MD. LLC (120)

Columbus Regional Health Care System (121)

Community Care Clinic Cedar Creek Church (122)

Community Clinic at Baton Rouge, The (123)

Community Health Partners (124)

Community Health Services (125)

Community Health Services Fremont (126)

Community Hospice Care Tiffin (127)

Community Hospitals and Wellness Centers (128)

Community Memorial Hospital (129)

Community Mercy Health Partners (130)

Comprehensive Family Practice of Michael Neverauskas DO (131)

Confer-Seeley, Kim (133)

Corporation El Ayudante De Laboatories Divination Nicaragua American Central (134)

Country Creek Family Physicians Rochester Michigan (136)

Cuyahoga County Board of Health (137)

Danbury Local School District (138)

Darlington Nursing and Rehab Center (139)

Dasani, Suresh (140)

Defiance Clinic (Fauster-Cameron Inc. dba Defiance Clinic) (141)

Defiance County Health Department (142)

Defiance Family Practice (143)

Defiance Ortho Center (144)

Defiance Regional Hospital (145)

Defiance Regional Medical Center (146)

Delta Medical Center (147)

Dermatology Assoc. (148)

Dermatology Partners (149)

DeVries, Brent, D.O. (150)

Dialysis Partners of Northwest Ohio (151)

Diller, Jonathon, MD (152)

Diroff,Corinne, CNM Associates in OB/GYN (153)

Dood, Steven (154)

Doumet, Mahdi MD (155)

Drs. Detrick and Detrick (156)

Dundee Corporate Connection (157)

Dwight Schar College of Nursing and Health Sciences (158)

East Toledo Family Center (159)

Eastern Michigan University (160)

Elmore Medical Association Inc. (161)

Elmwood Local Schools (162)

Elyria City Health Department (163)

Elyria School District Board of Education (164)

Emergency Physicians of Northwest Ohio (165)

Endocrine and Diabetes Center (166)

Endocrine and Diabetes Center for Advanced Care (167)

Endocrine Specialists, PC (Monroe, MI) (168)

Endocrine Specialists, PC (Toledo, OH) (169)

ENT Physician's, Inc. (Oregon, OH) (170)

EPNO (172)

Erie County General Health District (173)

Erie County Health Department (174)

Erie County MRDD (175)

Erie West Hospice & Palliative Care (176)

Erwin, Kermit R., MD (177)

Evercare a United Health Group Clinic (178)

Executive Court Medical Associates (179)

Fairchild, Darleen M.D. (180)

Falcon Health Center (181)

Fallen Timbers Family Physicians (182)

Family Health Riverview Center (183)

Family House; Toledo Community Service Center (185)

Family Medical Associates (186)

Family Medical Associates of Findlay (187)

Family Medical Center of Michigan (188)

Family Medical Office (189)

Family Medicine Associates (190)

Family Physicians of Lima (191)

Family Practice Clinic Erie County Health Dept. (192)

Family Practice of Hillsdale (193)

Family Practice of Toledo (195)

Fauster-Cameron, Inc. dba Defiance Clinic (196)

Fay, Lorraine, MD (198)

Federman, Douglas (199)

Felix, Charles G., M.D. (200)

Figy, Rex Neil, M.D. Office of (201)

Fireland Physician Group Family Practice (SAHEC) (202)

Firelands Physician Group Urgent Care (Clyde, OH) (203)

Firelands Physician Group Urgent Care (Sandusky, OH) (204)

Firelands Physicians Group (205)

Firelands Regional Medical Center (206)

Fisher Titus Care (207)

Fisher Titus Medical Care LLC (East Milan, OH) (208)

Fisher Titus Medical Care LLC (Wakeman, OH) (209)

Flat Rock Physicians (210)

Flower Hospital (211)

Flower Hospital Family Residency (212)

Fondessy, Terrence MD (213)

Forrest, Todd DO (214)

Fort Hays State University (215)

Fort Meigs Family Physicians (216)

Fostoria City Schools (217)

Fostoria Community Hospitals (218)

Fostoria Family Medicine (219)

Foundation Park Care Center (220)

Franklin Park Pediatrics (221)

Fremont Board of Education (222)

Fremont Family Medicine (223)

Fremont Medical Center (224)

Fremont Medical Clinic (225)

Fremont Memorial Hospital (226)

Fremont Walk In Medical Center (227)

Ft. Meigs Family Physicians (228)

Ft. Meigs Perrysburg Family Practice (229)

Fulton County Health Center (230)

Fulton County Health Center Emergency Department (231)

Fulton County Health Department (232)

Gase, Andrew MD Family Practice Office (233)

Geauga County General Health District (235)

Geisler, John MD (236)

Gibbs, Terry MD (237)

Gibsonburg Exempted Village School District (238)

Girl Scouts of Western Ohio (240)

Gottfried, James Allen (241)

Gray, Wm. J. M.D. (Morence, MI) (242)

Gray, Wm. J. M.D., Inc. (Blissfield, MI) (243)

Graystone Family Practice (244)

Great Lakes Medical Services (245)

Great Lakes Urgent Care (246)

Grillis, Michael D.O. (247)

Gross, Thomas M.D. (248)

Gutowski, Scott R. (249)

H. C. Providers, LLC (250)

Hackl, Pamela DO (251)

Hagerman Family Physicians (252)

Hancock County Health Department (253)

Harbor Behavioral Healthcare (254)

Harbor Family Practice (255)

Harwani, Ashok N., M.D. (256)

Health Partners of Western Ohio (257)

Health Specialists of Lenawee, P.C. (259)

Heartland - Holly Glen (260)

Heartland Hospice Services (261)

Heartland of Oregon (262)

Heartland of Perrysburg (263)

Heartland of Waterville (264)

Helping Hands of St. Louis (265)

Henry County Health Department (266)

Henry County Hospital (267)

Henry County Senior Center (268)

Henry Ford Wyandotte Hospital (269)

Heritage Healthcare Services (270)

Heritage Primary Care & Sports Medicine (271)

Hickman Cancer Center - Flower Memorial Hospital (272)

Hiestand, John, MD (273)

Hillsdale Pulmonary Critical Care (274)

Hilty Memorial Home (275)

HOA Cancer Center (276)

Hospice of Northwest Ohio (277)

Hospice of Western Reserve (278)

Hospice The-Caring-Way of Williams and Fulton Counties (279)

Hull, Charles MD (281)

HungKuang University (Grant) (282)

HungKuang University (Clinical Ageement) (283)

Huron County General Health District (284)

Huron Valley Neurology (285)

Husain, Syed Zakir, MD (286)

Independent Emergency Physicians (287)

Infectious Disease Associates (288)

Infectious Disease Luis Ernesto Jauregui-Peredo, M.D. (289)

Interim Healthcare (291)

Intermed Associates Inc. (292)

Internal Medicine Associates of S. E. Michigan (Ypsilanti, MI) (293)

Internal Medicine Associates of Southeast Michigan P.C. (Adrian, MI) (294)

Jauregui, Luis MD (296)

Jensen, Donna D.O. (297)

Johnson, Katherine, M.D. (298)

Joint Township District Memorial Hospital (299)

Jonathan Diller MD Inc (300)

Jonathan E. Pasko, M.D., PC (301)

Joy-Southfield Community Development Corporation, Inc. (302)

Juvenile Justice Clinic (304)

Kabir, Abdul, MD (305)

Kakarala, Prasad M.D. (306)

Kalus, Michael, MD ClevelandClinic (307)

Karamali, Adil M., M.D. Cardiocare (308)

Katz, Dr. Laura Alyce OB/GYN (309)

Kelin, Elizabeth, FNP, RN (310)

Kessler, Nancy MD (311)

Kidney and HTN Associates (312)

Kingston Care Center of Sylvania (313)

Kirk R. Davis, D.O. (314)

Komorowski, Frank S. MD LLC (315)

Lake County General Health District (317)

Lake Erie Nephrology & HTN (318)

Lake Local Schools (319)

Lampe, Teresa J. MD (320)

Lateef, Humaira MD., Harroun Rd. Family Phys. (321)

Laurels of Toledo ,The (322)

Liberty Center Schools (323)

Lima Family Care (324)

Lima Group Family Physicians (325)

Lima Memorial Health System (326)

Lima Memorial Hospital (327)

Little Clinic, The (328)

Little Sisters of the Poor (329)

Locust Pediatric Care Group, Inc. (330)

Lopez, Nicholas M., M.D. (331)

Lorain County Community College (332)

Lott Hill Adult Service Center (333)

Lourdes University (334)

Lucas County Board of Mental Retardation and Developmental Disabilities (335)

Lucas County Corrections Center (337)

Lucas County Health Dept. Nurse Midwifery and Women's Health (338)

Lucas County Health Dept. (339)

Lucas County Juvenile Detention Center (340)

Lutheran Homes Society Community Services (341)

Lutheran Village at Wolf Creek (342)

Magruder Hospital (343)

Maludy, Jeffrey M.D. (344)

Mansfield/Ontario/Richland County Health Department (345)

Mansion Street Women's Health PLLC (346)

Maple Creek Bucyrus Community Physicians (347)

Margaret Hunt Senior Center (348)

Marshall & Knieriem Family Medicine (349)

Marshall Internal & Family Medicine (Marshall, MI) (350)

Marshall Internal and Family (Tekonsha, MI) (351)

Martz and Martin Family Practice (352)

Masserant, John M.D. (353)

Mather, Arun D. MD (354)

Mattison, Timothy J. MD WellCare Physician Group (355)

Maumee Bay Family Practice (356)

Maumee Bay Obstetrics and Gynecology (357)

Maumee Bay Pediatrics (358)

Maumee Medical Partners LTD (359)

Maumee OB/GYN (360)

Maumee Pediatric Association (361)

MaxWell Clinic, The (362)

Medtapp Grant (363)

MEDF Physician's Corportation OB/GYN (364)

Memorial Health Care Systems (365)

Memorial Hospital (366)

Mercy Children's Hospital Foundation (367)

Mercy Children's Hospital Pediatric GI (368)

Mercy Children's Hospital Pediatric Urology (369)

Mercy College of Northwest Ohio (370)

Mercy Congenital Heart Specialists (371)

Mercy Family Physicians (372)

Mercy Family Physicians Point Shoreland (373)

Mercy Family Practice Perrysburg (374)

Mercy Family Practice Tiffin (375)

Mercy Health Center of Carroll County (376)

Mercy Hospital of Tiffin (377)

Mercy Medical Center (378)

Mercy Medical Center of Tuscarawas Cty. (379)

Mercy Memorial Hospital Emergency Department (380)

Mercy Memorial Hospital Monroe (381)

Mercy OB/GYN Associates (383)

Mercy OB/GYN Associates Perrysburg (384)

Mercy Orthopedic and Sports Medicine (Perrysburg, OH) (385)

Mercy Orthopedics & Sports Medicine (Carrollton, OH) (386)

Mercy Pediatric Association (387)

Mercy Post Acute (388)

Mercy Primary Care (389)

Mercy Primary Care Associates (Lorain, OH) (390)

Mercy Primary Care Associates (Swanton, OH) (391)

Mercy Regional Hospital (393)

Mercy St. Anne Hospital (394)

Mercy St. Charles Hospital (395)

Mercy St. Vincent Children's Hospital (396)

Mercy St. Vincent Medical Center (397)

Mercy Tiffin Hospital (398)

Metamora Family Practice (399)

Metro Health Medical Center (400)

Metrohealth Broadway (402)

Midwest Community Health Associates (403)

Midwest Community Health Association-BAHEC (404)

Midwest Community Health Group (405)

Midwest Community Health Associates (406)

Midwest Community Health/Parkview Physicians OB/GYN (407)

Mitchell Dermatology (408)

MK & SS Ahmed, MDs, Inc. (409)

MN Angels Adult & Pediatric Care (Bowling Green, OH) (410)

MN Angels Adult & Pediatric Care (Toledo, OH) (411)

Monclova Road Pediatrics (412)

Monroe County Community College (413)

Monroe County Sheriff's Department (414)

Monroe Health Center (415)

Monroe Mercy Hospital - Pediatric ED (416)

Montpelier Medical Center (417)

Nadaud, Mark C. D.O. (418)

Nationwide Children's Hospital (419)

Neighborhood Health Associates (420)

Neighborhood Health Association (421)

Nephrology Associates of Toledo (422)

New Beginnings Pediatrics (Maumee, OH) (423)

New Beginnings Pediatrics (Norwalk, OH) (424)

New Hanover County Health Department (425)

Newport Internal Medicine Newport Michigan (427)

Niese, Diane K. (428)

NOMS - Sandusky Northern Ohio Medical Specialists (429)

NOMS Family Practice (431)

NOMS Internal Medicine (432)

NOMS (OB/GYN) (433)

Nordonia Hills Clinic (Internal Medicine) (434)

North Central Women's Health (436)

North Coast Professionals Firelands Physician Group (437)

North Ohio Heart Inc. (Lorain, OH) (439)

North Ridgeville City Schools (440)

Northcoast Behavioral Health Care (441)

Northern Ohio Medical Specialists (Sandusky, OH) (442)

Northern Ohio Medical Specialists Urgent Care (443)

Northwest ENT Consultants (435)

Northwest Ohio Cardiology Consultants (Toledo, OH) (445)

Northwest Ohio Cardiology Consultants (Sandusky, OH) (446)

Northwest Ohio Center for Urogynecology and Women's Health (447)

Northwest Ohio Emergency Services (448)

Northwest Ohio Gastroenterology Associates (449)

Northwest Ohio Gastroenterology (450)

Northwest Ohio Health Partners (451)

Northwest Ohio OB/GYN (452)

Northwest Ohio Orthopedics and Sports (Bluffton, OH) (454)

Northwest Ohio Orthopedics-NOW (455)

Northwest Ohio Orthpedics & Sports Medicine, Inc (Findlay, OH) (456)

Northwest Ohio Partners in Women's Health (457)

Northwest Ohio Primary Care Physicians/Rossford Family Practice (458)

Northwest Ohio Psychiatric Hospital (Clyde, OH) (459)

Northwest Ohio Psychiatric Hospital (Toledo, OH) (460)

Northwest Ohio Urgent Care (Maumee, OH) (461)

Northwest Ohio Urgent Care (Sandusky, OH) (462)

Northwest Ohio Urgent Care, Inc. Network LLC (463)

Northwest Primary Care Physicians (Maumee, OH) (464)

Northwest Primary Care, Inc. (Clyde, OH) (465)

Northwest State Community College (466)

Northwest Surgical Specialists Inc. (467)

Northwood Local Schools (468)

Nucklos, Ruby, M.D. Ruppert Med. Center (469)

Nuga Pediatrics (470)

NWO Urgent Care/Bedford Urgent Care (471)

Office of Todd Robert Forrest,D.O. (472)

Ohio Heart and Vascular Consultants (473)

Ohio Northern University (474)

Ohio University School of Nursing (475)

OhioHealth Corporation (476)

OMNI Health Services, Ltd. (477)

Onslow Memorial Hospital (478)

Optum Clinical Services (479)

Orchard Villa (Cleveland, OH) (480)

Orchard Villa (Oregon, OH) (481)

Oregon Clinic, Inc. (2841 Munding, Oregon, OH) (482)

Oregon Clinic, Inc. (3841 Navarre Ave, Oregon, OH) (483)

Oregon Urgent Care and Family Practice (484)

Orra, Abdul M. D.O. (485)

Osowik, Rosemarie A., M.D. (486)

Owens Community College (30335 Oregon Rd., Perrysburg, OH) (488)

Owens State Community College Nursing Department (489)

Pappas, Angela Marie NP (490)

Pappas, S. John, M.D. (491)

Parker, Michael P., M.D. (492)

Parkside Care Corporation (493)

Parkside Surgery Center (494)

Parkview Phsycians Group Montpelier (495)

Parkview Physicians Group (496)

Partners in Primary Care (Montpelier, OH) (497)

Partners in Primary Care (Sandusky, OH) (498)

Pasko, Jonathan MD, PC (499)

Paulding County Hospital (500)

Paulding Exempted Village Schools (501)

Pediaticare Assoc. (502)

Pediatric Center, Inc. (503)

Pediatric Center, The (Adrian, MI) (504)

Pediatric Center, The (Lambertville, MI) (505)

Pediatric Center, The (Oregon, OH) (506)

Pediatric Center, The (Toledo, OH) (507)

Pediatric Fast Track/Mercy Memorial Hospital (508)

Pediatric Pulmonary Specialists (3400 Meijer Dr, Toledo, OH) (509)

Pediatric Pulmonary Specialists (2222 Cherry St., Toledo, OH) (510)

Pediatricare Associates (Lima, OH) (511)

Pediatricare Associates (Toledo, OH) (512)

Pediatrics at Center for Health Services (513)

Pediatrics of Lima (514)

Peninsula Medical Center (515)

Penta Career Center (516)

Peron, Slavador MD (517)

Perrysburg Family Physicians (518)

Perrysburg Fort Meigs Family Practice (519)

Perrysburg Pediatrics (520)

Personal Touch Deliveries (Sylvania, OH) (521)

Personal Touch Deliveries (Tiffin, OH) (522)

Physician Plus/Blanchard Valley Health System (523)

Physicians Plus Urgent Care (524)

Pickaway Health Services (Findlay, OH) (525)

Pickaway Health Services (Laurelville, OH) (526)

Planned Parenthood (Columbus, OH) (527)

Planned Parenthood (Toledo, OH) (528)

Port Clinton City School District (529)

Port Sylvania Family Physicians (530)

Power, Kenneth, M.D. (531)

PPG Adult Medicine Clinic (532)

PPG Harroun Road Family Physicians (533)

Premier Women's Health (534)

Premiere Family Practice (Massillon, OH) (535)

Premiere Family Practice (Westlake, OH) (536)

Prenancy Center of Greater Toledo, The (537)

Primary Care Associates (538)

Primary Care Partners of The Toledo Clinic (539)

Primary Care Partners (540)

ProMedica After Hours (541)

ProMedica Continuing Care Services Corporation (542)

ProMedica Health Systems, Inc (543)

ProMedica Hematology Oncology (547)

ProMedica Occuhealth Center for Health Services (Sylvania, OH) (548)

Promedica Occuhealth Center for Health Services (Toledo, OH) (549)

ProMedica Perrysburg Pediatrics (550)

ProMedica Physician Group, Inc. (551)

ProMedica Physicians & Continuum Services (552)

ProMedica Physicians Cardiology (553)

ProMedica Physicians Corporation (554)

ProMedica Physicians Morenci (555)

Promedica Urgent Care (556)

Puckett, Sarah, D.O. Drs. Puckett and Vannyen (OB/GYN) (557)

Pulmonary and Critical Care Specialists (558)

Putnam County Health Dept. (559)

Putnam County Primary Care (560)

R. W. Minick Medical Center (561)

Ragothaman, Krishna, M.D. (562)

Rao, Upamaka, M.D. (563)

Reconstructive and Aesthetic Surgeons (564)

Regency Park Clinic (565)

Regional Obstetrical Consultants (566)

Renal Services of Toledo Inc. (568)

Rescue Crisis Center (569)

Rescue Mental Health (570)

Respiratory & Infectious Disease,Inc. (571)

Rhodes State College (572)

Rinehart Family Health LLC (573)

River Road Family Physicians (574)

Rivercrest OB/GYN ProMedica aka/Wellcare Physicians Group (575)

Riverview Family Health (Perrysburg, OH) (577)

Riverview Family Health (Riverview, MI) (578)

Romius Institute Urology (579)

Rossford Family Practice (580)

Rossford Schools (581)

S.A.I.L., Inc. (582)

Sandusky Board of Developmental Disabilities (583)

Sandusky Career Center (584)

Sandusky City Schools and Sandusky Career Center Office of Career-Technical and Adult

Education (585)

Sandusky County Health Department (588)

Sandusky Family Practice (589)

Sandusky Pediatricians (590)

Sanjiv Josh, M.D. (591)

Scheer, Marvin, M.D. (592)

Scherer, Michael D.O. (593)

Secure Care, INC. (594)

Seneca County General Health District (595)

Shaker Heights City Health Department (596)

Shalini Singh, D.O. (597)

Sherwood Medical Center (598)

Singh, Parminder, M.D. (599)

Smolinski, Stephen M.D. Ph.D. (600)

Snider, Mark M.D. Family Practice (601)

Sood, Rama, M.D. (602)

South Pointe Hospital Cleveland Clinic (603)

South Toledo Internist (604)

South Toledo Pediatric Association (605)

Southern Care Toledo (606)

Southwest General Health Center (607)

Spencerville Local Schools (608)

Spino Sandra (609)

Spring Forest Family Physicians (610)

Springfield City Schools (611)

St Clare Commons (612)

St. Anne's Mercy Hospital (613)

St. Catherine's School (614)

St. Charles Emergency Department (615)

St. Francis de Sales High School (616)

St. George Urgent Care (Perrysburg, OH) (617)

St. George Urgent Care (Maumee, OH) (618)

St. John Baptist School (619)

St. John Jesuit High School (620)

St. John West Shore Hospital (621)

St. Luke's Hospital (622)

St. Luke's Hospital/ UT Family Medicine Residency (623)

St. Paul's Community Center (624)

St. Paul's Lutheran Church (625)

St. Riita's Hospital (626)

St. Rita's Medical Center (627)

St. Rita's Medical Center Emergency Department (628)

St. Rita's Professional Services (629)

St. Rita's Putnam County Ambulatory Care (630)

St. Rita's Urgent Care (631)

St. Vincent (Mercy St. V's) (632)

St. Vincent Charity Hospital-Ctr.for Vasc. Health (633)

St. Vincent Family Care Center (634)

St. Vincent Mercy Medical Center (635)

Stafford/Legacy Services Orchard Villa (636)

Stalter, Marvin D., M.D. (637)

Steele, D.O. (638)

Stein Hospice (Port Clinton, OH) (639)

Stein Hospice (Sandusky, OH) (640)

Strzesynski, Caroline (641)

Summa Akron City and St. Thomas Hospitals (642)

Sunforest OB/GYN (643)

Sunset Retirement Communities (644)

Surgery Center at Regency Park (645)

Swan Creek Health Care Center (646)

Swann, Gary F., DO OB-GYN (647)

Swanton Family Physicians (648)

Swartz, Jeffery, MD NWOCPCP (649)

Sylvan Oak Family Physicians (650)

Sylvania Adult and Pediatric Medicine (651)

Sylvania Family Physicians (Toledo, OH) (652)

Sylvania Family Physicians, LLC (Sylvania, OH) (653)

Sylvania Schools (654)

Sylvania Urgent Care (655)

Take Care Health System (656)

Tecumseh Family Practice (657)

Tender Touch Pediatrics, A (658)

Terra Community College (Tecumseh, MI) (659)

Terra Community College (Toledo, OH) (660)

Tharp, Kathleen R., CNP (661)

Timberstone Family Physicians (2150 W. Central Ave, Toledo, OH) (662)

Timberstone Family Physicians (4411 Holland-Sylvania Rd, Toledo, OH) (663)

Toledo Cardiology Consultants (664)

Toledo Center for Health Services (5210 Renwyck Dr., Toledo, OH) (665)

Toledo Center for Health Services (2150 W. Central Ave, Toledo, OH) (793)

Toledo Children's Heart Center (667)

Toledo Children's Hospital ( 4411 Holland Sylvania Ave, Toledo, OH) (668)

Toledo Children's Hospital (2142 N. Cove Blvd, Toledo, OH) (669)

Toledo Children's Primary Care (670)

Toledo Clinic IM/Endocrinology (671)

Toledo Clinic Cardiology (672)

Toledo Clinic General Surgery (673)

Toledo Clinic Ambulatory Surgery Center, The (674)

Toledo Clinic Cancer Center (675)

Toledo Clinic Dermatology/Dermtologic Surgery (676)

Toledo Clinic Family Practice, The (677)

Toledo Clinic Neurology (678)

Toledo Clinic Family Medicine (679)

Toledo Clinic Nephrology (680)

Toledo Clinic, The (681)

Toledo Clinic/Hematology-Oncology (683)

Toledo Community Service Center (684)

Toledo Hospital (685)

Toledo Hospital Emergency Department (686)

Toledo Internal Medical Specialists (2142 N. Cove Blvd., Toledo, OH) (687)

Toledo Internal Medical Specialists Inc. (5270 Renwyck Dr, Toledo, OH) (688)

Toledo Internal Medicine Specialists (689)

Toledo Lucas County Health Department (690)

Toledo Peds, Inc. (691)

Toledo Public Schools (692)

Toledo Radiological Group Assoc. Inc. (693)

Toledo VA Outpatient Clinic (694)

Traboulssi, Mourhaf, MD (695)

Tubbs Jones, Stephanie OB/GYN (696)

Tuttle, Cindy FNP, RN (697)

Twin Oaks Pediatrics (698)

Unison Behavioioral Health Group (3949 Sunforest Court, Toledo, OH) (699)

Unison Behavioral Health Group (1425 Starr Avenue, Toledo, OH) (700)

University Hospitals Cleveland (701)

University of Michigan (702)

University of Michigan Medical Center (703)

University of Toledo Medical Center, The (704)

University of Toledo Physicians, LLC (705)

Upper Valley Medical Center (706)

UT Physicians Heart & Vascular (707)

UTMC - Neurology Clinic (708)

UTMC - Ryan White Clinic Infectious Diseases (709)

UTMC Acute Care (710)

UTMC Dermatology Clinic (711)

UTMC Emergency Department (712)

UTMC Endocrinology (713)

UTMC Family Medicine (714)

UTMC Geriatrics (715)

UTMC Heart and Vascular Center (716)

UTMC Infectious Disease Clinic (717)

UTMC OB/GYN Clinic (718)

UTMC Ortho Center (719)

UTMC Pain Management Clinic (720)

UTMC Urology Clinic (721)

UTMC Wound Care Clinic (722)

UTMC Oncology (723)

UTMC Pediatrics (724)

UTMC-Surgery Cardic Thoracic Surgery (725)

VA Ann Arbor Healthcare System (726)

VA Clinic Toledo (727)

VA Health Systems Cardiology (728)

Van Kainen, Barbara (729)

Van Wert Medical Services (730)

Van Wert Visiting Nurse Association (731)

Vannuyen, Jackie, M.D. OB/GYN (732)

Vascular Professionals Inc. Clark and Kasper (733)

Victory Center (734)

Waldron, Laura, M.D. (735)

Walk In Urgent Care (Bowling Green, OH) (736)

Walk-In Urgent Care (Tiffin, OH) (737)

Walk-In Urgent Care (Toledo, OH) (738)

Washington Local Schools (739)

Waterford Commons (740)

Waterville Family Physicians (741)

Webb-Smith, Frances, M.D. (742)

Wellcare Physicians Group, LLC (743)

Wellcare Physicians of Promedica (744)

West Central Med. Group (745)

West Central Ohio Cardiology, Inc. (746)

West Ohio Family Physicians (Maumee, OH) (747)

West Ohio Family Physicians (Wauseon, OH) (748)

West Ohio Orthopedics (749)

West Toledo Internal Medicine (Sylvania, OH) (750)

West Toledo Internal Medicine Associates (Wauseon, OH) (751)

Westfield OB/GYN (752)

Westgate Medical Group (753)

Wexler, Wendy, M.D. (754)

White, Benjamin, D.O. (755)

Wildwood Family Practice (756)

Wildwood Surgical Center (757)

Willard City Schools (758)

Wilson Care, LLC (759)

Wilson Memorial Hospital (760)

Wishing Well Pediatrics (761)

Wohlwend Family Practice, Inc. (762)

Women's & Children's Center (763)

Women's Adolescent Health (764)

Women's Answer, A (765)

Women's Family Service (766)

Women's Health Center (767)

Women's Health Clinic Sandusky County (768)

Women's Health for Life (Findlay, OH) (769)

Women's Health for LIfe Inc. (Lima, OH) (770)

Women's Health Specialists (771)

Women's Place, A (772)

Wonderly, Mary MD (773)

Wood County Committee on Aging (774)

Wood County Community Health & Wellness Center (775)

Wood County Emergency Department (776)

Wood County Health Department (777)

Wood County Health District (778)

Wood County Hospital (779)

Wood County Medical Assoc. (755 Haskins Road, Bowling Green, OH) (780)

Wood County Medical Associates (970 W. Wooster Street, Bowling Green, OH) (781)

Wood County Pediatrics (782)

Wood County Women's Care (783)

Wood Health Corporation (784)

Wood, Robert F., MD (785)

Woodley Park Internal Medicine (786)

Woodville Family Practice (787)

Wright State University (788)

WW Knight Family Practice (789)

YWCA of Greater Toledo (790)

Zepf Center (791)

Zubair, Iram, M.D. (792)

CLINICAL LOCATION IS NOT IN LIST (11)

Answer If 7.1. Please select your clinical location from the list below. Please examine all

options for your clinical location before selecting your response. If you don't see your clinical

location in th... CLINICAL LOCATION IS NOT IN LIST Is Selected

Q7.1a 7.1a. Please provide the name of your clinical location in the box below.

Q7.2 7.2. Please provide the following information about your clinical location.

Name of Unit/Department (2)

Address (3)

City (4)

State (two letter abbreviation) (5)

Zip Code (6)

Phone Number of Clinical Location (XXX-XXX-XXXX) (7)

Q7.3 7.3. Is this clinical location owned by a parent agency?

Yes (1)

No (2)

Answer If Is the clinical site/agency/office owned by a parent agency? Yes Is Selected

Q7.3a 7.3a. Please provide the name of the parent organization.

Name of Parent Organization (1)

Address (2)

City (3)

State (two letter abbreviation) (4)

Zip Code (5)

Phone Number ((XXX-XXX-XXXX)) (6)

Q7.4 7.4. Do you have a second clinical location where you will be precepting students?

Yes (1)

No (2)

If No Is Selected, Then Skip To End of Block

Q7.5 7.5. Please select your second clinical location from the list below. Please examine all

options for your clinical location before selecting your response. If you don't see your

clinical location in the list, please select "CLINICAL LOCATION IS NOT IN LIST" at

the bottom of the drop down list.

Ability Center of Greater Toledo, The (13)

Adolecent & Young Adult Health Services (14)

Advanced Neurologic Assoc., Inc. (15)

Advanced Specialty Hospital (16)

AHEC (Huron, OH) (17)

AHEC (Toledo, OH) (18)

AHEC (OB/GYN) (19)

Airport Pediatrics (20)

Airport Urgent Care (21)

Alexis Medical Center (22)

All About Women (23)

Allegiance Health (24)

Allen County Health Department (25)

Allen County Health Partners (26)

Alliance for Women's Health (27)

Alliance Health Emergency (28)

American Health Network of Ohio PC (29)

Anne Grady Day Program (30)

Anthony Wayne Schools (31)

APRN Health Care Providers (32)

Area Office on Aging Northwest Ohio (33)

Arrowhead Behavioral Healthcare (34)

Arrowhead Family Physicians (35)

Arthur-Menasch MD (36)

AseraCare Hospice (37)

Associates in Women's Health (38)

Asthma and Allergy Care Center (39)

Autism Model School, The (40)

Baldwin Wallace University (41)

Barnett, Robert M.D (42)

Baton Rouge Health Services (43)

Batton Rouge Senior Health Services (44)

Bay Park Family Practice (45)

Bay Park Hospital (46)

Bay Park Hospital Emergency Department (47)

Bay Park Internal Medicine (48)

Bay Park Women's Health (49)

Bay Park Women's Services (50)

Bayshore OB/GYN (51)

Bayside Women's Center (52)

Beach House, The (54)

Beach, Patricia (CNS-Pallative Care) (55)

Beasley, Gary R. DO (56)

Bedford Family Physicians (57)

Behavioral Connections of Wood County (58)

Bellevue City Schools (59)

Bellevue Hospital (60)

Bellevue Professional Services (61)

Bixby Hospital and Emergency Department (62)

Black, Marianne (63)

Blanchard Family Physicians (64)

Blanchard Valley Health System (Hem/Onc Internal Medicine) (65)

Blanchard Valley Health System: (66)

Blanchard Valley Hospital (67)

Blanchard Valley Medical Associates (68)

Blanchard Valley Medical Association (69)

Blanchard Valley Regional Health Center (70)

Blanchard Valley Surgical Specialists (71)

Blanchard Valley Women's Care (72)

Blissfield Family Care (73)

Bluffton Physicians, Inc. (74)

Bluffton Women's Care (75)

BMC&EMC (76)

Bodie, David MD (77)

Borgess Center for Diabetes Care (78)

Bowes, Robert (OB/GYN) (79)

Bowling Green City Schools (80)

Bowling Green Clinic (81)

Bowling Green Family Care Center (82)

Bowling Green Family Physicians (83)

Bowling Green Student Health Services (84)

Boyce, Vanessa K. (85)

Boys & Girls Club of Toledo (86)

Branch Hillsdale St. Joseph Community Health Agency (87)

Bronson Lakeview Family Ca