Contact InformationName of Health Center*Name of individual completing this form* First Last Title*Email* Enter Email Confirm Email Phone*Please answer the following with as much detail as possible:Please enter # of requested FNP Residents*What is the anticipated address where the FNP Resident(s) will work?*Why is your health center interested in participating in this FNP Residency Program?*Describe any challenges your health center is currently facing recruiting and retaining FNPs.*Who will serve as the Preceptor(s) for the FNP Resident? Provide their name, title and e-mail.*Note: each Resident must have a Primary and Secondary Preceptor (FNP, NP, MD, or DO with at least 2 years of experience)Will your health center be able to reduce the Preceptor's patient panel to allow time for them to meet with the FNP Resident? Describe any challenges you foresee. (Note: any patients taken from the Preceptor's panel can be given to the FNP Resident)*What specialties does your clinic have that the FNP Resident(s) can rotate through? For example: HIV Clinic, Women's Health, etc.*What is the estimated salary you expect to offer the FNP Resident(s)?*Any special request? Such as the FNP Resident(s) must be bilingual or must have experience with a certain populations)Please list any questions you may still have regarding the FNP Residency Program?
