Clinical Agency Roster Clinical Agency Name and address Unit name Agency Contact phone number and email (person that will be able to provide information regarding the student and faculty performance on the unit) Date of Contract Nursing course name/number and type of clinical experiences obtained Number of students per clinical unit per day/ hrs on unit Total number of students per term/ Total Hours in direct client / Indicate preceptor experiences with * Accrediting Body; date and results of most recent accreditation Example: The Best Hospital 1414 Oak Lane Richmond, VA Unit: 4 south Mary Lou Who 331-111-1111 mlw@Bestplace. 3/10/2010- 3/10/2015 Medical Surgical I, NURS 122 Medical surgical nursing care 6 students per day/8 hr 12 students per term/80 clinical hours direct care TJC 2014/good standing met all standards 1. 2. 3. 4. 5. 6.
5. Respond to the board's request for additional information within a timeframe established by the board. Provide the Board with current information regarding employment opportunities for graduates of your proposed program. Employment opportunities should be in the geographical location of the nursing program. Provide information regarding the programs plan to prepare students for the NCLEX. Provide a plan of the proposed Systematic Plan of Evaluation to evaluate learning resources, facilities and services. Refer to 18VAC 90-27-190-A 18VAC90-27-40. Organization and administration. The governing or parent institution offering Virginia nursing education programs be approved by the Virginia Department of Education or SCHEV or accredited by an accrediting agency recognized by the U.S. Department of Education. <INSERT APPROVAL AND OR ACCREDITATION FROM ACCREDITING AGNECY HERE> (Other examples of supporting evidence may include: Recent ACEN or AACN Accreditation Self-Study; State education agreement, SARA certificate). B. Any Agency or institution used for clinical experience by a nursing program be in good standing with its licensing body. (Refer to Clinical Agency Roster) C. The program director of the nursing education program shall: 1. Hold a current license or multistate licensure privilege to practice as a registered nurse in the Commonwealth without any disciplinary action that currently restricts practice;
CURRENT FACULTY RANK/TITLE NAME FULL TIME/ PART TIME Date of initial hire COLLEGE/ UNIVERSITY NURSING CREDENTIAL HIGHEST DEGREE OBTAINED MAJOR TEACHING RESPONSIBILITY YEARS EXPERIENCE in NURSING PRACTICE YEARS EXPERIENCE TEACHING in an academic setting OF LICENSE NUMBER AND EXP. DATE Example: Mary Who Associate Professor Full time 3/10/2000 Best University RN, MS, DNP, CCRN DNP Care MedSurg 25 14 VA 12/31/2015
Practice medications Barlow tape and equipment Thermometers (electronic) Sphygmomanometer Teaching stethoscopes Sharps container wheelchairs Medication administration Supplies to teach Baby care supplies Cord care supplies Oral and personal hygiene equipment Bath basins, emesis basins, towels, wash clothes, soap, tooth paste, hair care, skin care Ambulation equipment Gait belts Canes Crutches walkers care supplies Various skin treatments i.e.:Duoderm Infant scales Measuring tapes Scales chair, standing Anti-embolic stockings Linens, linen hampers Hospital cribs Pressure prevention protectors Heel protectors Pillows Medication dispensing unit Medication administration supplies for all routes Practice medications for all routes Surgical care supplies Sterile gloves Wound drains – i.e.: hemovac, Jackson Pratt, penrose Infection Control equipment Gowns Head cover Mask Gloves Shoe covers Nutritional Supplies Foods Cups Utensils Diet trays Snellen’s chart Oxygen equipment Nasal prong Simple mask oximetry Incentive spirometer Naso-gastric tubes and insertion supplies