Preceptor Demographic Form

On an annual basis, we must submit reports to the Commonwealth of Massachusetts Board of Registration in Nursing (BORN). BORN requires (*) we provide them information on our preceptors. To comply with their request, we need your assistance by completing the information below. Please return to your student who will submit it to the Regis Seminar Instructor by week 3 of the semester. (Failure to submit will create a clinical warning.)

BSN at the least is required by the BORN for overseeing. Please have the BSN overseeing the experience fill out this form (Nurse Manager­/Clinical Educator if necessary.)

* required

Student Name*
Semester*
Program*
Course*
Preceptor Name*
City/Town*
State/Country*
Name of Clinical Agency*
Number of students for whom you are a preceptor this term
Massachusetts Nurse Registration Number*
Name on License (if different from above)
Expiration Date*
Type*

Educational Background

Undergraduate Institution*
Undergraduate Degree Earned*
Year Undergraduate Completed*
Graduate (Masters) Institution
Graduate Degree Earned*
Year Graduate Completed*
Doctorate Institution
Doctorate Degree Earned
Year Doctorate Completed

For More Information

Deborah Henderson

Director, Pre-Licensure Clinical Experiences

Jillian Costa

Coordinator for Complex Care preceptorships

Regis College School of Nursing: Preceptor Demographic Form
On an annual basis, we must submit reports to the Commonwealth of Massachusetts Board of Registration in Nursing (BORN). BORN requires (*) we provide them information on our preceptors.