# Post Master's DNP Clinical Partners Handbook

**<span style="font-size: 26.0pt; mso-bidi-font-size: 12.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span></span>**

**<span style="font-size: 26.0pt; mso-bidi-font-size: 12.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span>DNP Practice Partner</span>**

**<span style="font-size: 26.0pt; mso-bidi-font-size: 12.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span>Handbook</span>**

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**<span style="font-size: 24.0pt; mso-bidi-font-size: 12.0pt; line-height: 107%;">DNP Post-Master’s Degree Option </span>**

**<span style="font-size: 24.0pt; mso-bidi-font-size: 12.0pt; line-height: 107%;">Practice Partner Manual</span>**

**<span style="font-size: 24.0pt; mso-bidi-font-size: 12.0pt; line-height: 107%;"> </span>**

**<span style="font-size: 12.0pt;">Disclaimer Statement</span>**<span style="font-size: 12.0pt;">: These guidelines have been prepared to inform you of the selected policies, procedures, and activities within Arkansas State University’s DNP Post-master’s option.</span>

<span style="font-size: 12.0pt;">As registered nurses, graduate students must adhere to all rules and</span>

<span style="font-size: 12.0pt;">regulations in the Nurse Practice Act in your state.</span>

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**<span style="font-size: 10.0pt; mso-bidi-font-size: 12.0pt; font-family: 'Arial',sans-serif; mso-fareast-font-family: Arial;">COLLEGE OF NURSING AND HEALTH PROFESSIONS </span>**

<span style="mso-spacerun: yes;"> </span><span style="font-size: 9.0pt; mso-bidi-font-size: 12.0pt; font-family: 'Arial',sans-serif; mso-fareast-font-family: Arial;">Graduate School of Nursing | P.O. Box 910, State University, AR 72467 | P: 870-972-3701 | F: 870-972-2954 </span>

# <span style="font-size: 11.0pt; mso-bidi-font-size: 12.0pt; line-height: 105%;"> </span>

# <span style="font-size: 11.0pt; mso-bidi-font-size: 12.0pt; line-height: 105%;">COLLEGE OF NURSING AND HEALTH PROFESSIONS </span>

School of Nursing | P.O. Box 910, State University, AR 72467 | P: 870-972-3074 | F: 870-972-2954

<span style="font-size: 9.0pt; mso-bidi-font-size: 12.0pt; line-height: 107%; font-family: 'Arial',sans-serif; mso-fareast-font-family: Arial;">Rev. ; 01.30.24 LL; 07.28.25 LD; 06.19.26</span>

<span style="font-size: 14.0pt; mso-bidi-font-size: 12.0pt; line-height: 110%; font-family: 'Calibri',sans-serif; mso-fareast-font-family: Calibri; color: #2f5496;">Letter to Practice Partner </span>

Dear Practice Partner,

A Doctor of Nursing Practice student’s Practice Partner has a crucial role in preparing the student for a future in practice change. We are very grateful for your willingness to share your expertise and professional time with our graduate students.<span style="mso-spacerun: yes;"> </span>

The guidelines presented in this Practice Partner Handbook are designed to provide you with supporting information for the project courses.<span style="mso-spacerun: yes;"> </span>Your role as a Practice Partner is to mentor the students as they learn the role of the Doctor of Nursing Practice related to a Quality Improvement project. The student does not always have to be with you physically. You can identify meetings and experiences that may be beneficial to student learning and support your student’s role as a Doctor of Nursing Practice.<span style="mso-spacerun: yes;"> </span>

We cannot express our appreciation enough for the time you take to mentor and guide our students. This practice partnership is a valuable experience for students because it provides them with the opportunity to apply what they have learned in their project courses to prepare them for future roles.<span style="mso-spacerun: yes;"> </span>

Please let us know if you have any questions, concerns, or even ideas for program improvement. Nursing is a team effort and we value your contribution to the students’ educational experience!<span style="mso-spacerun: yes;"> </span>

Sincerely,

Dr. Lisa Drake

DNP Program Director

870-972-3701

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<span style="font-size: 9.0pt;"> </span>

<span style="font-size: 9.0pt;">The Associate, Baccalaureate, Master's, master’s/post-master's certificate, and clinical doctorate programs at Arkansas State University located in State University, AR and West Memphis, AR are accredited by the: Accreditation Commission for Education in Nursing (ACEN). 3390 Peachtree Road NE, Suite 1400 Atlanta, GA 30326 (404) 975-5000</span>

<span style="font-size: 9.0pt;"> </span>

<span style="font-size: 9.0pt;"> </span>

<span style="font-size: 9.0pt;">The most recent accreditation decision made by the ACEN Board of Commissioners for the Associate, Baccalaureate, Master's, graduate/post-master's certificate, and clinical doctorate programs is continuing accreditation. </span>

<span style="font-size: 9.0pt;">View the public information disclosed by the ACEN regarding this program </span>[<span style="font-size: 9.0pt;">on the ACEN website</span>](http://www.acenursing.com/accreditedprograms/programsearch.htm "http://www.acenursing.com/accreditedprograms/programsearch.htm")

**<span style="font-size: 9.0pt;"> </span>**

<span style="font-size: 14.0pt; mso-bidi-font-size: 12.0pt; line-height: 110%; font-family: 'Calibri',sans-serif; mso-fareast-font-family: Calibri; color: #2f5496;"> </span>

**<span style="font-size: 14.0pt; mso-bidi-font-size: 12.0pt; line-height: 110%; font-family: 'Calibri',sans-serif; mso-fareast-font-family: Calibri; color: windowtext;">DNP Practice Partner</span>**

**Practice Partner (Preceptor):**

The Post-Master’s DNP program uses practice partners as preceptors. The practice partner role definition is: A terminally degreed expert (DNP, MD, EdD, PhD, and in some cases Pharm D), who agrees to provide support and guidance for a DNP student completing a post-master's DNP project experience.<span style="mso-spacerun: yes;"> </span>The Practice Partner must have at least 2 years of work experience in the last 5 years.<span style="mso-spacerun: yes;"> </span>The practice partner cannot be a family member or spouse due to a conflict of interest. If the practice partner is an RN or an MD, license verification must be included.

**Practice Partner Agreement**:

The Practice Partner is asked to complete an A-State School of Nursing Practice Partner Agreement, along with a CV, an acknowledgment statement that they received the handbook, license verification, and return it to the DNP student, who will submit it to Verified Credentials for faculty approval.

If the practice partner works as an employee at the DNP Student’s workplace, where the DNP Project will be completed, the practice partner will complete Document 4: Clinical Practice Partner Site Agreement Form and include a CV, an acknowledgment statement, and a license verification form (RN or MD).

If the practice partner is not from the DNP Student’s workplace but is located at the place where the DNP Project is taking place, they will complete Document #3: Arkansas State University School of Nursing Clinical Practice Partner Verification Form and include a CV, acknowledgment statement, and license verification form (RN or MD).

**Practice Partner Activities (beginning):**

<span style="font-family: 'Times New Roman',serif; mso-fareast-font-family: 'Times New Roman';"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span><span style="font-family: 'Times New Roman',serif;">Share helpful contacts within the facility.</span>

<span style="font-family: 'Times New Roman',serif; mso-fareast-font-family: 'Times New Roman';"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span><span style="font-family: 'Times New Roman',serif;">Assist with needs assessment at the facility.</span>

<span style="font-family: 'Times New Roman',serif; mso-fareast-font-family: 'Times New Roman';"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span><span style="font-family: 'Times New Roman',serif;">Assist in selecting a topic for the student’s quality improvement project (not a research project).</span>

<span style="font-family: 'Times New Roman',serif; mso-fareast-font-family: 'Times New Roman';"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span><span style="font-family: 'Times New Roman',serif;">Answer questions about Quality Improvement Projects or implementation of evidence into practice (sometimes called translation science) at the facility.</span>

<span style="font-family: 'Times New Roman',serif; mso-fareast-font-family: 'Times New Roman';"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span><span style="font-family: 'Times New Roman',serif;">Assist with the scheduling process of team meetings/committees related to the DNP QI Project (preparing and conducting).</span>

<span style="font-family: 'Times New Roman',serif; mso-fareast-font-family: 'Times New Roman';"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span><span style="font-family: 'Times New Roman',serif;">Clarify legal, policy, and ethical issues at the facility.</span>

<span style="font-family: 'Times New Roman',serif; mso-fareast-font-family: 'Times New Roman';"><span style="mso-list: Ignore;">7.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span><span style="font-family: 'Times New Roman',serif;">Facilitate student access to appropriate project-related data.</span>

<span style="font-family: 'Times New Roman',serif; mso-fareast-font-family: 'Times New Roman';"><span style="mso-list: Ignore;">8.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span><span style="font-family: 'Times New Roman',serif;">The Practice Partner is not responsible for teaching the student or grading assignments \*\* </span>

**Practice Partners Activities (during project):**

<span style="font-family: 'Times New Roman',serif; mso-fareast-font-family: 'Times New Roman';"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span><span style="font-family: 'Times New Roman',serif;">Communicate periodically with the student on practicum or project progress and outcomes (how things are going).</span>

<span style="font-family: 'Times New Roman',serif; mso-fareast-font-family: 'Times New Roman';"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span><span style="font-family: 'Times New Roman',serif;">Notify the faculty if there is a breach in professionalism by the student.</span>

<span style="font-family: 'Times New Roman',serif; mso-fareast-font-family: 'Times New Roman';"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span><span style="font-family: 'Times New Roman',serif;">The practice partner serves as a mentor during the process of the DNP Project.</span>

**<span style="font-family: 'Times New Roman',serif;"> </span>**

**Practice Partners Activities (after project):**

<span style="font-family: 'Times New Roman',serif; mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-weight: bold;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span><span style="font-family: 'Times New Roman',serif;">The Practice Partner will receive a Qualtrics survey link (created by PM DNP NURS 88263 course </span>

<span style="font-family: 'Times New Roman',serif;">faculty) and will be sent by the student to evaluate student performance. </span>

**DNP Student (after project):**

<span style="font-family: 'Times New Roman',serif; mso-fareast-font-family: 'Times New Roman';"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span><span style="font-family: 'Times New Roman',serif;">The DNP student will receive a Qualtrics survey link from the program director to evaluate the facility. </span>

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## <span style="font-size: 11.0pt; line-height: 110%;"><span style="mso-spacerun: yes;"> </span>Student Expectations for the Project Site</span>

**Note: The DNP Practice Partner is a preceptor; however, they will not teach students or grade their assignments.<span style="mso-spacerun: yes;"> </span>All assignments will be submitted to the ASTATE course in Canvas.<span style="mso-spacerun: yes;"> </span>The Practice Partner will serve as a mentor for the DNP Project.** <span style="mso-spacerun: yes;"> </span>

<span style="font-size: 12.0pt;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span>The student contacts the DNP Practice Partner concerning questions they may have about the DNP Project site.

<span style="font-size: 12.0pt;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span>The student works with the Director, course faculty, and the DNP Administrative Assistant to ensure Practice Partner agreements are signed. The student will obtain information from the Practice Partner and upload all required documents for approval. These documents will be reviewed, and the student will be notified if the Practice Partner is approved.

<span style="font-size: 12.0pt;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span>The student will collaborate with the Practice Partner to develop a schedule if the student needs mentoring related to the project site.

<span style="font-size: 12.0pt;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span>The student will adhere to the A-State Professionalism Policy for the course. The student will always conduct him or herself in a professional manner during the Practice Partnership.

As part of the DNP Project expectations, students are to:

<span style="font-size: 12.0pt;"><span style="mso-list: Ignore;">•<span style="font: 7.0pt 'Times New Roman';"> </span></span></span>Provide the Practice Partner with the Practice Partner and Student Handbooks.

<span style="font-size: 12.0pt;"><span style="mso-list: Ignore;">•<span style="font: 7.0pt 'Times New Roman';"> </span></span></span>Meet course outcomes that align with the AACN Essentials and the student DNP project.

<span style="font-size: 12.0pt;"><span style="mso-list: Ignore;">•<span style="font: 7.0pt 'Times New Roman';"> </span></span></span>Complete the Student Evaluation of Facility

**<span style="font-size: 14.0pt; mso-bidi-font-size: 12.0pt; line-height: 107%;"> </span>**

**<span style="font-size: 12.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span>Nursing Program/Course Faculty Responsibilities </span>**

<span style="font-size: 12.0pt;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span>Assumes overall responsibility for teaching and evaluation of the student.

<span style="font-size: 12.0pt;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span>Assure student compliance with project and required clinical documents.

<span style="font-size: 12.0pt;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span>Readily available by phone or email for consultation as needed.

<span style="font-size: 12.0pt;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span>Review portfolio and clinical log with the student and provide feedback as indicated or needed.

<span style="font-size: 12.0pt;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span>Facilitate student progression through all facets of the DNP Project paper and presentation.

Before enrolling in NURS 8213 Translational Research I, students must submit the following DNP project documents for review and approval. This is a crucial step for the DNP Project and a necessary component for obtaining IRB approval. Failure to submit and receive approval will put the student at risk of course failure as the IRB approval is a requirement for the course.

<span style="mso-bidi-font-size: 11.0pt;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span>Site Permission letter: Document 1 if completing project at workplace or affiliation agreement secured.

<span style="mso-bidi-font-size: 11.0pt;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span>Affiliation Agreement: Document 2 if completing project outside of workplace. Once the contract is approved and signed, Document 1 must be completed and signed by the project site.

<span style="mso-bidi-font-size: 11.0pt;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span>Practice Partner Agreement: Document 3 if completing project outside of workplace.

<span style="mso-bidi-font-size: 11.0pt;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span>Practice Partner Agreement: Document 4 if completing project at workplace.

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**<span style="font-size: 12.0pt; mso-fareast-font-family: Calibri; color: windowtext;">Degree Plans of Study</span>**

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## Full-Time Degree Plan – Doctor of Nursing Practice General

### Core

NURS 88173: Leadership, Policy, and Healthcare Systems<span style="mso-spacerun: yes;"> </span>

NURS 88143: Healthcare Finance in Advanced Nursing<span style="mso-spacerun: yes;"> </span>

NURS 88153: Healthcare Informatics in Advanced Nursing<span style="mso-spacerun: yes;"> </span>

NURS 88203: Translational Research for Doctor of Nursing Practice I<span style="mso-spacerun: yes;"> </span>

NURS 88223: Translational Research for Doctor of Nursing Practice II

NURS 88263: DNP Project<span style="mso-spacerun: yes;"> </span>

NURS 88303: DNP Internship I (180 clinical hours)<span style="mso-spacerun: yes;"> </span>

NURS 88343: DNP Internship II (180 clinical hours)<span style="mso-spacerun: yes;"> </span>

NURS 88333: DNP Internship III (180 clinical hours)<span style="mso-spacerun: yes;"> </span>

NURS 8887V: DNP Internship IV<span style="mso-spacerun: yes;"> </span>

### Concentration

NURS 88103: Theoretical Foundations for Doctor of Nursing Practice

NURS 88133: Epidemiology for the DNP<span style="mso-spacerun: yes;"> </span>

NURS 88163: Principles of Healthcare Ethics &amp; Genetics<span style="mso-spacerun: yes;"> </span>

## Full-Time Degree Plan – Doctor of Nursing Practice Education

### Core

NURS 88173: Leadership, Policy, and Healthcare Systems<span style="mso-spacerun: yes;"> </span>

NURS 88143: Healthcare Finance in Advanced Nursing<span style="mso-spacerun: yes;"> </span>

NURS 88153: Healthcare Informatics in Advanced Nursing<span style="mso-spacerun: yes;"> </span>

NURS 88203: Translational Research for Doctor of Nursing Practice I<span style="mso-spacerun: yes;"> </span>

NURS 88223: Translational Research for Doctor of Nursing Practice II

NURS 88263: DNP Project<span style="mso-spacerun: yes;"> </span>

NURS 88303: DNP Internship I (180 clinical hours)<span style="mso-spacerun: yes;"> </span>

NURS 88343: DNP Internship II (180 clinical hours)<span style="mso-spacerun: yes;"> </span>

NURS 88333: DNP Internship III (180 clinical hours)<span style="mso-spacerun: yes;"> </span>

NURS 8887V: DNP Internship IV<span style="mso-spacerun: yes;"> </span>

### Concentration

NURS 66053: Measurement and Evaluation in Health Sciences

NURS 66603: Curriculum Development in Health Professions<span style="mso-spacerun: yes;"> </span>

NURS 66853: Teaching in Advanced Nursing Roles<span style="mso-spacerun: yes;"> </span>

## Full-Time Degree Plan – Doctor of Nursing Practice Executive Leadership

### Core

NURS 88173: Leadership, Policy, and Healthcare Systems<span style="mso-spacerun: yes;"> </span>

NURS 88143: Healthcare Finance in Advanced Nursing<span style="mso-spacerun: yes;"> </span>

NURS 88153: Healthcare Informatics in Advanced Nursing<span style="mso-spacerun: yes;"> </span>

NURS 88203: Translational Research for Doctor of Nursing Practice I<span style="mso-spacerun: yes;"> </span>

NURS 88223: Translational Research for Doctor of Nursing Practice II

NURS 88263: DNP Project<span style="mso-spacerun: yes;"> </span>

NURS 88303: DNP Internship I (180 clinical hours)<span style="mso-spacerun: yes;"> </span>

NURS 88343: DNP Internship II (180 clinical hours)<span style="mso-spacerun: yes;"> </span>

NURS 88333: DNP Internship III (180 clinical hours)<span style="mso-spacerun: yes;"> </span>

NURS 8887V: DNP Internship IV<span style="mso-spacerun: yes;"> </span>

### Concentration

NURS 55133: Leadership in Health Professions<span style="mso-spacerun: yes;"> </span>

NURS 66373: Healthcare Law and Quality Improvement

NURS 66353: Budgeting and Financial Management<span style="mso-spacerun: yes;"> </span>

**Student Evaluation of Facility**

Practice Partner Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_<u style="text-underline: black;"> </u>Term:<span style="mso-spacerun: yes;"> </span>![]()\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Constructive evaluation is a valuable tool utilized by the faculty as a method for quality control of the curriculum. Student evaluations are viewed by the faculty and administration as one method for maintaining high, consistent levels of quality education in the School of Nursing. As a professional nursing student, evaluation requires maturity and objectivity. This evaluation tool is the student’s opportunity to participate in the ongoing evaluation process. Please read each item carefully, then select the category that you feel correlates with your feelings about the statement.<span style="mso-spacerun: yes;"> </span>

Rating scale:<span style="mso-spacerun: yes;"> </span>

4 = Excellent

3 = Above average

2 = Average

1 = Needs improvement<span style="mso-spacerun: yes;"> </span>

<table border="0" cellpadding="0" cellspacing="0" class="TableGrid" id="bkmrk-practicum-applicatio" style="width: 440.6pt; margin-left: 36.95pt; border-collapse: collapse; mso-yfti-tbllook: 1184; mso-padding-alt: 3.5pt 9.1pt 0in .25pt;" width="587"><tbody><tr style="mso-yfti-irow: 0; mso-yfti-firstrow: yes; height: 24.65pt;"><td style="width: 350.8pt; border: solid black 1.0pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 24.65pt;" valign="top" width="468">Practicum Applications

</td><td style="width: .25in; border: solid black 1.0pt; border-left: none; mso-border-left-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 24.65pt;" valign="top" width="24">4

</td><td style="width: 18.05pt; border: solid black 1.0pt; border-left: none; mso-border-left-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 24.65pt;" valign="top" width="24">3

</td><td style="width: .25in; border: solid black 1.0pt; border-left: none; mso-border-left-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 24.65pt;" valign="top" width="24">2

</td><td style="width: .25in; border: solid black 1.0pt; border-left: none; mso-border-left-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 24.65pt;" valign="top" width="24">1

</td><td style="width: 17.75pt; border: solid black 1.0pt; border-left: none; mso-border-left-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 24.65pt;" valign="top" width="24">0

</td></tr><tr style="mso-yfti-irow: 1; height: 28.3pt;"><td style="width: 350.8pt; border: solid black 1.0pt; border-top: none; mso-border-top-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 28.3pt;" valign="top" width="468">1\. The practicum facility was appropriate and offered adequate learning opportunities through the needs assessment.

</td><td style="width: .25in; border-top: none; border-left: none; border-bottom: solid black 1.0pt; border-right: solid black 1.0pt; mso-border-top-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 28.3pt;" valign="top" width="24"></td><td style="width: 18.05pt; border-top: none; border-left: none; border-bottom: solid black 1.0pt; border-right: solid black 1.0pt; mso-border-top-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 28.3pt;" valign="top" width="24"></td><td style="width: .25in; border-top: none; border-left: none; border-bottom: solid black 1.0pt; border-right: solid black 1.0pt; mso-border-top-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 28.3pt;" valign="top" width="24"></td><td style="width: .25in; border-top: none; border-left: none; border-bottom: solid black 1.0pt; border-right: solid black 1.0pt; mso-border-top-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 28.3pt;" valign="top" width="24"></td><td style="width: 17.75pt; border-top: none; border-left: none; border-bottom: solid black 1.0pt; border-right: solid black 1.0pt; mso-border-top-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 28.3pt;" valign="top" width="24"></td></tr><tr style="mso-yfti-irow: 2; height: 28.45pt;"><td style="width: 350.8pt; border: solid black 1.0pt; border-top: none; mso-border-top-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 28.45pt;" valign="top" width="468">2\. The facility provided the resources needed to plan for a Quality Improvement Project, including multidisciplinary collaboration.

</td><td style="width: .25in; border-top: none; border-left: none; border-bottom: solid black 1.0pt; border-right: solid black 1.0pt; mso-border-top-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 28.45pt;" valign="top" width="24"></td><td style="width: 18.05pt; border-top: none; border-left: none; border-bottom: solid black 1.0pt; border-right: solid black 1.0pt; mso-border-top-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 28.45pt;" valign="top" width="24"></td><td style="width: .25in; border-top: none; border-left: none; border-bottom: solid black 1.0pt; border-right: solid black 1.0pt; mso-border-top-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 28.45pt;" valign="top" width="24"></td><td style="width: .25in; border-top: none; border-left: none; border-bottom: solid black 1.0pt; border-right: solid black 1.0pt; mso-border-top-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 28.45pt;" valign="top" width="24"></td><td style="width: 17.75pt; border-top: none; border-left: none; border-bottom: solid black 1.0pt; border-right: solid black 1.0pt; mso-border-top-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 28.45pt;" valign="top" width="24"></td></tr><tr style="mso-yfti-irow: 3; height: 28.45pt;"><td style="width: 350.8pt; border: solid black 1.0pt; border-top: none; mso-border-top-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 28.45pt;" valign="top" width="468">3\. The facility accommodated student experiences by providing confidential access to deidentified data without interaction with patients.

</td><td style="width: .25in; border-top: none; border-left: none; border-bottom: solid black 1.0pt; border-right: solid black 1.0pt; mso-border-top-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 28.45pt;" valign="top" width="24"></td><td style="width: 18.05pt; border-top: none; border-left: none; border-bottom: solid black 1.0pt; border-right: solid black 1.0pt; mso-border-top-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 28.45pt;" valign="top" width="24"></td><td style="width: .25in; border-top: none; border-left: none; border-bottom: solid black 1.0pt; border-right: solid black 1.0pt; mso-border-top-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 28.45pt;" valign="top" width="24"></td><td style="width: .25in; border-top: none; border-left: none; border-bottom: solid black 1.0pt; border-right: solid black 1.0pt; mso-border-top-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 28.45pt;" valign="top" width="24"></td><td style="width: 17.75pt; border-top: none; border-left: none; border-bottom: solid black 1.0pt; border-right: solid black 1.0pt; mso-border-top-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 28.45pt;" valign="top" width="24"></td></tr><tr style="mso-yfti-irow: 4; mso-yfti-lastrow: yes; height: 28.45pt;"><td style="width: 350.8pt; border: solid black 1.0pt; border-top: none; mso-border-top-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 28.45pt;" valign="top" width="468">4\. The facility onboarding process (i.e., facility student orientation) was well organized and easy to complete.

</td><td style="width: .25in; border-top: none; border-left: none; border-bottom: solid black 1.0pt; border-right: solid black 1.0pt; mso-border-top-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 28.45pt;" valign="top" width="24"></td><td style="width: 18.05pt; border-top: none; border-left: none; border-bottom: solid black 1.0pt; border-right: solid black 1.0pt; mso-border-top-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 28.45pt;" valign="top" width="24"></td><td style="width: .25in; border-top: none; border-left: none; border-bottom: solid black 1.0pt; border-right: solid black 1.0pt; mso-border-top-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 28.45pt;" valign="top" width="24"></td><td style="width: .25in; border-top: none; border-left: none; border-bottom: solid black 1.0pt; border-right: solid black 1.0pt; mso-border-top-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 28.45pt;" valign="top" width="24"></td><td style="width: 17.75pt; border-top: none; border-left: none; border-bottom: solid black 1.0pt; border-right: solid black 1.0pt; mso-border-top-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-alt: solid black .5pt; padding: 3.5pt 9.1pt 0in .25pt; height: 28.45pt;" valign="top" width="24"></td></tr></tbody></table>

<span style="font-size: 10.0pt; line-height: 103%;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span>What are the strengths of this facility to assist the student with the implementation of the DNP QI Project?

<span style="font-size: 10.0pt; line-height: 103%;"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span>What suggestions do you have for enhancing experiences at this facility?

Additional comments (your comments are appreciated and are used to ensure that experiences are appropriate):<span style="mso-spacerun: yes;"> </span>

**Preceptor Evaluation of Student**

Student Name:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Dates:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Practice Partner/Preceptor:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Thank you for the opportunities that you provided for the student during the course of the semester. This is an opportunity for you to share your view on the student’s performance. Please share your perceptions by rating the student on the following items and adding any comments you desire. Your input is valued and appreciated.

Rate: Fair (1), Proficient (2), Excellent (3)

<span style="mso-bidi-font-family: Aptos; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span>Integrates advanced nursing knowledge of the DNP role and systems.

<span style="mso-bidi-font-family: Aptos; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span>Proposes culturally appropriate solutions to foster quality improvement and safe care.

<span style="mso-bidi-font-family: Aptos; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span>Maintains professional relationships and timely interaction with the project chair, and the project site team.

Score 1(Fair); 2 (Proficient); 3 (Excellent)

<span style="mso-bidi-font-family: Aptos; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span>Functions as a professional role model.

<span style="mso-bidi-font-family: Aptos; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span>Demonstrates leadership skills through effective planning, providing, and managing a quality improvement project.

<span style="mso-bidi-font-family: Aptos; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span>Demonstrates initiative in identifying opportunities for self-development.

<span style="mso-bidi-font-family: Aptos; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">7.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span>Serves as a resource person by assisting with problem identification and resolution.

<span style="mso-bidi-font-family: Aptos; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">8.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span>Utilizes ethical/legal guidelines that apply to nursing role development.

<span style="mso-bidi-font-family: Aptos; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">9.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span>Maintains current knowledge in an evidence-based approach in decision making.

<span style="mso-bidi-font-family: Aptos; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">10.<span style="font: 7.0pt 'Times New Roman';"> </span></span></span>Contributes to positive work (collaborates, consults, coordination).

Strengths: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Needs improvement: \_\_\_\_\_\_\_\_\_\_\_\_\_\_

Preceptor Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

## 1. SAMPLE SCHOOL/SITE PERMISSION LETTER

Required for all students

\[**<span style="background: yellow;">MUST Place on clinical site’s letterhead</span>**\]

Date

Arkansas State University – Jonesboro Institutional Review Board<span style="mso-spacerun: yes;"> </span>

c/o Research and Technology Transfer Post Office Box 2760 State University, Arkansas 72467<span style="mso-spacerun: yes;"> </span>

To Whom It May Concern:

A Doctor of Nursing Practice student in the Arkansas State University-Jonesboro Department of Nursing has requested permission to complete the Doctor of Nursing Practice Project named below at {<u style="text-underline: black;">Insert</u> <u style="text-underline: black;">School/Institution/Clinic Name</u>} during the period of {<u style="text-underline: black;">Insert Start Date</u>} to {<u style="text-underline: black;">Insert End Date</u>}.<span style="mso-spacerun: yes;"> </span>

This letter notifies you that I/we grant permission to {<u style="text-underline: black;">Insert Student Name</u>}, a student of Arkansas State University-Jonesboro Doctor of Nursing Practice Program, to collect data at the location listed below.<span style="mso-spacerun: yes;"> </span>

Project Title: {insert your quality improvement project title here}<span style="mso-spacerun: yes;"> </span>

Principal Investigator(s): {insert your name here – must be a student only}

Study Site Location: <span style="mso-tab-count: 1;"> </span>{insert Institution/Clinic name here}

{Street address} {City, State, zip code}<span style="mso-spacerun: yes;"> </span>

Permission granted by:

![]()

Print Name and Title

Signature <span style="mso-tab-count: 1;"> </span><span style="mso-spacerun: yes;"> </span>Date

**<span style="font-size: 14.0pt; line-height: 103%;">DNP Project Completion Site (Affiliation) Request</span>**

**<span style="font-size: 14.0pt;">Document 2 (<span style="background: yellow; mso-highlight: yellow;">If you are NOT completing the project at your place of<span style="mso-spacerun: yes;"> </span>employment</span>)</span>**

# <span style="font-size: 12.5pt; mso-bidi-font-size: 12.0pt; line-height: 107%;"> </span>

Please immediately upload the document as directed in your DNP program. Delays in submitting this Site Request may disrupt the original plan of study and delay program completion. PLEASE TYPE INFORMATION.<span style="mso-spacerun: yes;"> </span>If you need an affiliation agreement/contract, this is the form to begin with in the DNP Project process. Do not complete Document 1 until this is done and a contract is secured. This document is if you are not completing the project at your workplace or if the project site is requesting an agreement.

<span style="font-size: 10.5pt; mso-bidi-font-size: 12.0pt; line-height: 106%;"><span style="mso-spacerun: yes;"> </span>Student Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_</span>

<span style="font-size: 10.5pt; mso-bidi-font-size: 12.0pt; line-height: 106%;"> </span>

**<span style="font-size: 10.5pt; mso-bidi-font-size: 12.0pt; line-height: 106%;">Name of the desired site</span>**<span style="font-size: 10.5pt; mso-bidi-font-size: 12.0pt; line-height: 106%;"> for DNP project completion: </span><span style="mso-spacerun: yes;"> </span>

<span style="font-size: 10.5pt; mso-bidi-font-size: 12.0pt; line-height: 106%;">\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ </span>

**<span style="font-size: 10.5pt; mso-bidi-font-size: 12.0pt; line-height: 106%;">Physical address</span>**<span style="font-size: 10.5pt; mso-bidi-font-size: 12.0pt; line-height: 106%;"> of the chosen site for DNP project completion:<span style="mso-spacerun: yes;"> </span></span><span style="mso-spacerun: yes;"> </span>

<span style="font-size: 10.5pt; mso-bidi-font-size: 12.0pt; line-height: 106%;">\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_</span>

**<span style="font-size: 10.5pt; mso-bidi-font-size: 12.0pt; line-height: 183%;">Name and role </span>**<span style="font-size: 10.5pt; mso-bidi-font-size: 12.0pt; line-height: 183%;">of the person at this site authorized to sign clinical affiliation agreements: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_</span>

**<span style="font-size: 10.5pt; mso-bidi-font-size: 12.0pt; line-height: 106%;">Email address and phone number </span>**<span style="font-size: 10.5pt; mso-bidi-font-size: 12.0pt; line-height: 106%;">of the person authorized to sign clinical affiliation agreements: </span><span style="mso-spacerun: yes;"> </span>

<span style="font-size: 10.5pt; mso-bidi-font-size: 12.0pt; line-height: 106%;">\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_</span>

**3<span style="font-size: 12.0pt; line-height: 110%;">. Arkansas State University School of Nursing Clinical Practice Partner Verification Form</span>**

## <span style="background: yellow;">(Use if you are NOT completing your project at your place of employment</span>)

**Directions**: Identify a terminally degreed expert who is willing to coach/mentor you in your efforts to complete your project. Ask them to complete this form. Once completed, electronically upload this form **along with the Practice Partner’s CV** as directed in your DNP Program. RN and MD must provide license verification documentation from their state board.

Note: Illegible forms will be returned to the student.<span style="mso-spacerun: yes;"> </span>

DNP Student Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Clinical Practice Partner’s Name &amp; Credentials<span style="mso-spacerun: yes;"> </span>

(Must have a terminal degree such as DNP, PhD, EdD, PharmD, MD):<span style="mso-spacerun: yes;"> </span>\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_<span style="mso-spacerun: yes;"> </span>

Clinical Practice Partner’s Title/position<span style="mso-spacerun: yes;"> </span>

(Such as Administrator, Educator, Physician, CNO, Dean):

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_<span style="mso-spacerun: yes;"> </span>

Clinical Practice Partner’s Employer: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Clinical Practice Partner Employer’s Address: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

RN and APRN (if applicable) license number/s including state\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_<span style="mso-spacerun: yes;"> </span>

Clinical Practice Partner’s Contact information:

Email:<span style="mso-spacerun: yes;"> </span>\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Telephone number: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Mailing Address: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

### Terms of Agreement<span style="mso-spacerun: yes;"> </span>

I agree to be the practice partner for the student listed above during the time needed to complete the DNP project for A-State’s School of Nursing and will submit a current CV to the above-listed student. I am aware of the time and responsibility that is required to advance student learning. I understand the student is not allowed patient interaction for this project. I verify that I am employed at the facility where the DNP project will be completed.<span style="mso-spacerun: yes;"> </span>

Practice Partner Signature <span style="mso-tab-count: 1;"> </span>Date

Please Print Name<span style="mso-spacerun: yes;"> </span>

**<span style="font-size: 14.0pt; mso-bidi-font-size: 12.0pt; line-height: 107%;">Arkansas State University Post Masters DNP Program </span>**

**<span style="font-size: 14.0pt; mso-bidi-font-size: 12.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span>Document 4. Clinical Practice Partner Site Agreement Form<span style="mso-spacerun: yes;"> </span></span>**

**<span style="font-size: 14.0pt; mso-bidi-font-size: 12.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span>(<span style="background: yellow; mso-highlight: yellow;">Use if you <u style="text-underline: black;">ARE</u> completing your project at your place of employment</span>) </span>**<span style="font-size: 14.0pt; mso-bidi-font-size: 12.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span></span>

<span style="mso-spacerun: yes;"> </span>

**Directions:** Please upload the completed **Clinical Practice Partner Site document and the Practice Partner’s CV** as directed in your DNP program. Delays in submitting this Agreement may interrupt the original plan of study and delay the completion of the program.<span style="mso-spacerun: yes;"> </span>RN and MD must provide license verification documentation from their state board.

<span style="font-size: 9.0pt; line-height: 107%;">DNP Student Name<span style="mso-spacerun: yes;"> </span>\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_</span>

<span style="font-size: 9.0pt; line-height: 103%;"> </span>

<span style="font-size: 9.0pt; line-height: 103%;">Practice Partner Name:<u style="text-underline: black;"><span style="mso-spacerun: yes;"> </span>\_\_\_\_\_\_\_\_</u>\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_<span style="mso-spacerun: yes;"> </span></span>

<span style="font-size: 9.0pt; line-height: 103%;">Preferred Contact: Home Phone<u style="text-underline: black;"><span style="mso-spacerun: yes;"> </span><span style="mso-tab-count: 1;"> </span><span style="mso-spacerun: yes;"> </span></u>Cell <span style="mso-spacerun: yes;"> </span>Phone: \_\_\_\_\_\_\_\_\_\_\_\_\_<u style="text-underline: black;"> </u>E-mail \_\_\_\_\_\_\_\_\_\_\_\_\_<span style="mso-spacerun: yes;"> </span><span style="mso-tab-count: 1;"> </span><span style="mso-spacerun: yes;"> </span></span>

<span style="font-size: 9.0pt; line-height: 103%;">Title/Role: <span style="mso-tab-count: 1;"> </span>\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Credentials: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ <span style="mso-tab-count: 1;"> </span><span style="mso-spacerun: yes;"> </span></span>

<table border="0" cellpadding="0" cellspacing="0" class="TableGrid" id="bkmrk-license-%23%3A-_________" style="width: 551.6pt; border-collapse: collapse; mso-yfti-tbllook: 1184; mso-padding-alt: 0in 0in 0in 0in;" width="735"><tbody><tr style="mso-yfti-irow: 0; mso-yfti-firstrow: yes; height: 33.3pt;"><td style="width: 4.25in; padding: 0in 0in 0in 0in; height: 33.3pt;" valign="top" width="408"><span style="font-size: 9.0pt; line-height: 107%;">License #: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_<span style="mso-spacerun: yes;"> </span>State: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_</span>

</td><td style="width: 245.6pt; padding: 0in 0in 0in 0in; height: 33.3pt;" valign="top" width="327"><span style="font-size: 9.0pt; line-height: 107%;">Expiration Date:<u style="text-underline: black;"><span style="mso-spacerun: yes;"> </span><span style="mso-tab-count: 1;"> </span></u><span style="mso-spacerun: yes;"> </span></span>

</td></tr><tr style="mso-yfti-irow: 1; height: 28.55pt;"><td style="width: 4.25in; padding: 0in 0in 0in 0in; height: 28.55pt;" valign="top" width="408"><span style="font-size: 9.0pt; line-height: 107%;">Project Site Name (Must Match Site Permission Letter): <u style="text-underline: black;"><span style="mso-spacerun: yes;"> </span></u></span>

<u style="text-underline: black;"><span style="font-size: 9.0pt; line-height: 107%;"><span style="text-decoration: none;"> </span></span></u>

<u style="text-underline: black;"><span style="font-size: 9.0pt; line-height: 107%;">\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_</span></u><span style="font-size: 9.0pt; line-height: 107%;"> </span>

<span style="font-size: 9.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span></span>

</td><td style="width: 245.6pt; padding: 0in 0in 0in 0in; height: 28.55pt;" valign="top" width="327"><span style="font-size: 9.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span></span>

</td></tr><tr style="mso-yfti-irow: 2; mso-yfti-lastrow: yes; height: 13.1pt;"><td style="width: 4.25in; padding: 0in 0in 0in 0in; height: 13.1pt;" valign="top" width="408"><span style="font-size: 9.0pt; line-height: 107%;">Project Site Address:<u style="text-underline: black;"> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_</u> </span>

</td><td style="width: 245.6pt; padding: 0in 0in 0in 0in; height: 13.1pt;" valign="top" width="327"><span style="font-size: 9.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span></span>

</td></tr></tbody></table>

**<span style="font-size: 9.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span></span>**<span style="font-size: 9.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span></span>

**<span style="font-size: 9.0pt; line-height: 107%;">Terms of Agreement </span>**<span style="font-size: 9.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span></span>

<span style="font-size: 9.0pt; line-height: 107%;">I agree to be the practice partner for the student listed above during the time needed to complete the DNP project for A- State’s School of Nursing and I will provide a current CV for the student to submit to the School of Nursing. I am aware of the time and responsibility that is required to advance student learning. I understand the student is not allowed patient<span style="mso-spacerun: yes;"> </span>interaction for this project. I verify that I am employed at the facility where the DNP project will be completed.<span style="mso-spacerun: yes;"> </span></span>

<span style="font-size: 9.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span></span>

<span style="font-size: 9.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span></span>

<span style="font-size: 9.0pt; line-height: 103%; font-family: 'Calibri',sans-serif; mso-fareast-font-family: Calibri;"><span style="mso-tab-count: 1;"> </span><span style="mso-spacerun: yes;"> </span></span><span style="font-size: 9.0pt; line-height: 103%;">Practice Partner Signature <span style="mso-tab-count: 1;"> </span><span style="mso-tab-count: 1;"> </span>Date<span style="mso-spacerun: yes;"> </span></span>

<span style="font-size: 9.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span></span>

<span style="font-size: 9.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span></span>

<span style="font-size: 9.0pt; line-height: 103%;">Please Print Name<span style="mso-spacerun: yes;"> </span></span>

<span style="font-size: 9.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span></span>

**<span style="font-size: 9.0pt; line-height: 103%;">The DNP student agrees to the following. Please initial each statement and sign and date below: </span>**<span style="font-size: 9.0pt; line-height: 103%;"><span style="mso-spacerun: yes;"> </span></span>

**<span style="font-size: 9.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span></span>**<span style="font-size: 9.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span></span>

<span style="font-size: 9.0pt; line-height: 103%;"><span style="mso-spacerun: yes;"> </span>\_\_\_\_\_\_\_I agree to maintain professional liability insurance coverage as required by the DNP program for<span style="mso-spacerun: yes;"> </span>the duration of the period of time needed to complete the DNP project.<span style="mso-spacerun: yes;"> </span></span>

<span style="font-size: 9.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span></span>

<span style="font-size: 9.0pt; line-height: 103%;">\_\_\_\_\_\_\_I understand the DNP project does not involve contact with or treatment of any patient.<span style="mso-spacerun: yes;"> </span></span>

<span style="font-size: 9.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span></span>

<span style="font-size: 9.0pt; line-height: 103%;"><span style="mso-spacerun: yes;"> </span>\_\_\_\_\_\_\_I understand that patient health information cannot be utilized in the DNP project without execution of<span style="mso-spacerun: yes;"> </span>a clinical affiliation agreement between A-State and the clinical facility.<span style="mso-spacerun: yes;"> </span></span>

<span style="font-size: 9.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span></span>

<span style="font-size: 9.0pt; line-height: 103%;"><span style="mso-spacerun: yes;"> </span>\_\_\_\_\_\_\_I have spoken to my employer, where I will be completing my DNP project, and they have no<span style="mso-spacerun: yes;"> </span>objection or restrictions regarding the publication of my DNP project.<span style="mso-spacerun: yes;"> </span></span>

<span style="font-size: 9.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span></span>

<span style="font-size: 9.0pt; line-height: 107%;"> </span>

<span style="font-size: 9.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span></span>

<span style="font-size: 9.0pt; line-height: 103%;">Student Signature<span style="mso-tab-count: 3;"> </span>Date</span>

Printed Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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### <span style="font-size: 12.0pt; line-height: 110%;"> </span>

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### <span style="font-size: 12.0pt; line-height: 110%;"> </span>

<span style="font-size: 12.0pt; line-height: 110%;">Practice Partner Handbook Agreement</span>

<span style="font-size: 12.0pt; line-height: 110%;">I, (practice partner name), acknowledge that I have received and reviewed the Practice Partner Handbook. All my questions have been answered, and I understand my responsibilities to the AState DNP student, (DNP student name).</span>

<span style="font-size: 12.0pt; line-height: 110%;">Practice Partner Name:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_</span>

<span style="font-size: 12.0pt; line-height: 110%;">Name of Project Site: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_</span>

<span style="font-size: 12.0pt; line-height: 110%;">Role at Project Site: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_</span>

<span style="font-size: 12.0pt; line-height: 110%;">Contact Phone Number and Email: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_</span>

<span style="font-size: 12.0pt; line-height: 110%;">Date: \_\_\_\_\_\_\_\_\_\_\_\_\_ </span>

<span style="font-size: 12.0pt; line-height: 103%;"> </span>

<span style="font-size: 12.0pt; line-height: 103%;"> </span>

<span style="font-size: 12.0pt; line-height: 103%;">The DNP Student is responsible for submitting this document for approval.</span>

**<span style="font-size: 26.0pt; mso-bidi-font-size: 12.0pt; line-height: 107%;"><span style="mso-spacerun: yes;">  
</span></span>**

<span style="font-size: 16.0pt; mso-bidi-font-size: 12.0pt; line-height: 107%; font-family: 'Calibri',sans-serif; mso-fareast-font-family: Calibri; color: #2f5496;">Additional Information </span>

For more information regarding the Arkansas State University School of Nursing, click on the following link: [<span style="color: #0563c1;">https://www.astate.edu/college/conhp/departments/nursing/index.do</span>](https://www.astate.edu/college/conhp/departments/nursing/index.dot)[<span style="color: #0563c1;">t</span>](https://www.astate.edu/college/conhp/departments/nursing/index.dot)[<span style="color: black; text-decoration: none; text-underline: none;"> </span>](https://www.astate.edu/college/conhp/departments/nursing/index.dot)[<span style="color: black; text-decoration: none; text-underline: none;"><span style="mso-spacerun: yes;"> </span></span>](https://www.astate.edu/college/conhp/departments/nursing/index.dot)

For more information regarding the DNP Options, click on the following link:<span style="mso-spacerun: yes;"> </span>

[<span style="color: #0563c1;">https://www.astate.edu/college/conhp/departments/nursing/degrees</span>](https://www.astate.edu/college/conhp/departments/nursing/degrees/)[<span style="color: #0563c1;">/</span>](https://www.astate.edu/college/conhp/departments/nursing/degrees/)[<span style="color: black; text-decoration: none; text-underline: none;"> </span>](https://www.astate.edu/college/conhp/departments/nursing/degrees/)[<span style="color: black; text-decoration: none; text-underline: none;"><span style="mso-spacerun: yes;"> </span></span>](https://www.astate.edu/college/conhp/departments/nursing/degrees/)

For more information regarding the DNP, General option, click on the following link:<span style="mso-spacerun: yes;"> </span>

[<span style="color: #0563c1;">https://degree.astate.edu/programs/docto</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-general.aspx)[<span style="color: #0563c1;">r</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-general.aspx)[<span style="color: #0563c1;">-</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-general.aspx)[<span style="color: #0563c1;">o</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-general.aspx)[<span style="color: #0563c1;">f</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-general.aspx)[<span style="color: #0563c1;">-</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-general.aspx)[<span style="color: #0563c1;">nursin</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-general.aspx)[<span style="color: #0563c1;">g</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-general.aspx)[<span style="color: #0563c1;">-</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-general.aspx)[<span style="color: #0563c1;">practic</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-general.aspx)[<span style="color: #0563c1;">e</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-general.aspx)[<span style="color: #0563c1;">-</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-general.aspx)[<span style="color: #0563c1;">general.asp</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-general.aspx)[<span style="color: #0563c1;">x</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-general.aspx)[<span style="color: black; text-decoration: none; text-underline: none;"> </span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-general.aspx)[<span style="color: black; text-decoration: none; text-underline: none;"><span style="mso-spacerun: yes;"> </span></span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-general.aspx)

For more information regarding the DNP, Education option, click on the following link:<span style="mso-spacerun: yes;"> </span>

[<span style="color: #0563c1;">https://degree.astate.edu/programs/docto</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-education.aspx)[<span style="color: #0563c1;">r</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-education.aspx)[<span style="color: #0563c1;">-</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-education.aspx)[<span style="color: #0563c1;">o</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-education.aspx)[<span style="color: #0563c1;">f</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-education.aspx)[<span style="color: #0563c1;">-</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-education.aspx)[<span style="color: #0563c1;">nursin</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-education.aspx)[<span style="color: #0563c1;">g</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-education.aspx)[<span style="color: #0563c1;">-</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-education.aspx)[<span style="color: #0563c1;">practic</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-education.aspx)[<span style="color: #0563c1;">e</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-education.aspx)[<span style="color: #0563c1;">-</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-education.aspx)[<span style="color: #0563c1;">education.asp</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-education.aspx)[<span style="color: #0563c1;">x</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-education.aspx)[<span style="color: black; text-decoration: none; text-underline: none;"> </span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-education.aspx)[<span style="color: black; text-decoration: none; text-underline: none;"><span style="mso-spacerun: yes;"> </span></span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-education.aspx)

For more information regarding the DNP, Leadership option, click on the following link:<span style="mso-spacerun: yes;"> </span>[<span style="color: #0563c1;">https://degree.astate.edu/programs/docto</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-leadership.aspx)[<span style="color: #0563c1;">r</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-leadership.aspx)[<span style="color: #0563c1;">-</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-leadership.aspx)[<span style="color: #0563c1;">o</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-leadership.aspx)[<span style="color: #0563c1;">f</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-leadership.aspx)[<span style="color: #0563c1;">-</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-leadership.aspx)[<span style="color: #0563c1;">nursin</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-leadership.aspx)[<span style="color: #0563c1;">g</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-leadership.aspx)[<span style="color: #0563c1;">-</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-leadership.aspx)[<span style="color: #0563c1;">practic</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-leadership.aspx)[<span style="color: #0563c1;">e</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-leadership.aspx)[<span style="color: #0563c1;">-</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-leadership.aspx)[<span style="color: #0563c1;">leadership.asp</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-leadership.aspx)[<span style="color: #0563c1;">x</span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-leadership.aspx)[<span style="color: black; text-decoration: none; text-underline: none;"> </span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-leadership.aspx)[<span style="color: black; text-decoration: none; text-underline: none;"><span style="mso-spacerun: yes;"> </span></span>](https://degree.astate.edu/programs/doctor-of-nursing-practice-leadership.aspx)

13