Preceptor Evaluation Hands-on Training 
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Email *
1. Nurse's Name *
2. Nursing Credentials
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3. Date of Form Completion
(Example: January 7, 2019)
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4. Nurse's Email 
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5. Nurse's Mailing Address *
6. Preceptor's  Name    (Needs to be: DPM, CFCN, CFCS)                         
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7. Preceptor's Institution
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8. Preceptor's Credentials
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9. Preceptor's Email Address or Phone 
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10. Location of Training
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11. Dates & Hours of Training Each Day
 Example: 9/10/24 3 hrs,   9-12-24 2 hrs,   10-10-24 3 hrs
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12. Total Training Hours (Minimum 30 hrs)
Example: 30 Hours *
Preceptor Duties and Requirements:


1. Demonstrate proper instrument use and techniques for a variety of nail/callus conditions to the Nurse.
2. Monitor Nurse while they are performing toenail and callus reduction/debridement on patients/clients.
3. While both Preceptor and Nurse may each perform care on each patient, the Nurse must do most of the actual reduction/trimming under the supervision and direction of the Preceptor.
4. This training is intended to be “Hands-on” care by the Nurse. Simply observing the Preceptor providing all the care is not acceptable.
5. The hours of training listed should reflect work performed by the Nurse under the supervision and demonstration efforts by the Proctor.

Please indicate how well the Nurse:

13. Demonstrated the ability to use instruments appropriately to achieve toenail and callous trimming, sanding, reduction:
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Required
Please indicate how well the Nurse:

14. Demonstrated an understanding of appropriate care for iatrogenic lesions. This should include control of bleeding, cleansing the lesion site, medicating and dressing the lesion site:
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Required
Please indicate how well the Nurse:

15. Demonstrated a good working relationship and communication skills with the patient/client during the treatment session:
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Required
Please indicate how well the Nurse:

16. Demonstrated the ability to perform a lower extremity physical examination:
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Required
Please indicate how well the Nurse:

17. Demonstrated an understanding of the equipment and materials used to perform toenail and hyperkeratotic lesion reduction:
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Required
Please indicate how well the Nurse:

18. Demonstrated an understanding of issues surrounding instrument disinfection, prevention of cross-contamination, patient/client and personal protective equipment:
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Required
Verification of Training                                                                                              
Signature of Preceptor
(Typing your name below constitutes a legal signature and verifies that you have performed the required Preceptor duties and evaluation written on this form)
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Date of Signing
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A copy of your responses will be emailed to the address you provided.
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