The ANCC preceptor form, officially the Preceptorship Documentation Form (CPM-FRM-050), is a one-page record of the clinical supervision hours you are claiming for Renewal Category 5 toward your five-year certification renewal. You fill it in yourself, get a faculty coordinator to sign it, and keep it in your own files. You do not send it to ANCC with your renewal application unless you are later selected for audit.1American Nurses Credentialing Center. ANCC Preceptorship Documentation Form
What the Form Asks For
Download CPM-FRM-050 from the certification section of nursingworld.org. The fields are short, but each one has to match your actual records because this document is the only thing standing between you and a failed audit.1American Nurses Credentialing Center. ANCC Preceptorship Documentation Form
- Total preceptorship hours completed. The number must meet or exceed 120.
- Name of the student, fellow, resident, or intern you precepted.
- Start and end dates of the preceptorship, which must fall within your current certification cycle.
- Specialty area or focus of the preceptorship, which should relate to your certification.
- Facility name where the work took place.
Before you write anything down, pull your personal logs and compare them to the facility’s records. If the hours on your form do not match what the institution has on file, an auditor will see the discrepancy immediately. Do not round up or estimate. The form is a professional attestation, and inaccurate information can result in disciplinary action against your certification.
The Faculty Coordinator Signature
The lower portion of the form has to be signed by the faculty coordinator for the academic program, fellowship, residency, or internship. You will need their printed name and credentials, title, educational institution, program name, institution address, phone number, signature, and date.1American Nurses Credentialing Center. ANCC Preceptorship Documentation Form
Get this signature as soon as the hours are complete. Coordinators change jobs, programs restructure, and chasing down someone two or three years after the fact is often where renewals fall apart. A form without the coordinator’s signature is incomplete and will not satisfy an audit.
Which Hours Actually Qualify
You need at least 120 hours of direct clinical supervision or teaching during your current five-year certification period, and ANCC accepts either of two pathways:2American Nurses Credentialing Center. ANCC Certification Renewal Handbook
- Direct clinical supervision or teaching of students enrolled in an academic program related to your certification specialty.
- At least 120 hours of clinical supervision in a formal fellowship, residency, or internship program at the same practice level as your certification or higher.
If you hold a Clinical Nurse Specialist or Nurse Practitioner certification, your academic-pathway preceptees have to be APRN, medical, physician assistant, or pharmacy students in a program related to your certification population.2American Nurses Credentialing Center. ANCC Certification Renewal Handbook
Three common situations do not qualify. Orientation preceptor hours are not accepted, no matter how many you have logged walking new hires through unit protocols. Preceptor hours cannot double as practice hours for your renewal; they belong in Category 5 and nowhere else. And if you are faculty in a nursing program, clinical supervision of students in your own educational program does not count toward this category.2American Nurses Credentialing Center. ANCC Certification Renewal Handbook
Keep the Form, Do Not Submit It
The form itself says: “Please do NOT submit this page with your renewal application. Keep this form with your records in case of audit.”1American Nurses Credentialing Center. ANCC Preceptorship Documentation Form
When you renew, you log into your account at nursingworld.org, open your certification, and enter your professional development activities — including the preceptorship hours — directly in the online application.3ANA. ANCC Nursing Certification Renewal You are self-reporting. The signed form sits in your personal files as proof. Keep a digital backup alongside any paper copy, and hang onto it through your entire next renewal cycle.
If You Are Audited
ANCC runs random audits on renewal applications. Selected applicants receive an email asking for documentation of the continuing education hours and professional development activities they claimed. For Category 5, the signed Preceptorship Documentation Form is what you produce.2American Nurses Credentialing Center. ANCC Certification Renewal Handbook
Failing to respond, or failing to fully document compliance, can result in disciplinary action against your certification. That phrase covers everything from a missing coordinator signature to hours that do not match what you reported online. The signed form is the only evidence backing a Category 5 claim, so treat it accordingly.