This question requires a valid email address.
11. Please document dates (from/to) for each of the specialty areas with which you have past of present experience (choose all that apply): *This question is required.
12. Indicate your nursing education date issued month/year (choose all that apply): *This question is required.
Scan a copy of your certificate and email to CHTP@dhhs.nc.gov
If you do not have a copy of your certificate, the Office of Chief Public Health Nurse at the N.C. Division of Public Health, office number 919-707-5130, maintains course rosters.
14. Preceptor Qualifications: The primary preceptor must be an advanced practice provider or physician. It is strongly recommended that the provider have a specialty of Pediatrics or Family Medicine. Secondary preceptor(s), if applicable, may be a rostered CHERRN with a minimum of 2 years clinical practice. See the 2024-2025 CHTP Local Planning Document for more details. *This question is required.
15. Provide the following information on the primary preceptor and secondary preceptor (if applicable): *This question is required.
16. Provide the following information on the Nursing Director and Clinical Supervisor: *This question is required.
17. Provide the following information regarding the physician who will provide standing orders (if applicable): *This question is required.