PRIMARY HEALTH CARE NURSE PRACTITIONER CERTIFICATE

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1 PRIMARY HEALTH CARE NURSE PRACTITIONER CERTIFICATE Clinical Placmnt Packag

2 Tabl of Contnts Clinical Placmnt Guidlins... 2 List of Rquird Forms & Supporting Documntation... 2 PHCNP Crtificat Powrpoint Undrstanding Clinical Placmnts... 5 PHCNP Practic Rquirmnt Rcord PHCNP Practic Information Rcord PHCNP WSIB Studnt Dclaration of Undrstanding PHCNP Clinical Placmnt Packag Documnts Chcklist

3 Clinical Placmnt Guidlins To hlp you complt your Clinical Placmnt Packag w hav cratd a documnts guid. Upon accssing th Clinical Placmnt Guid you will s information and instructions on both th rquird supporting documnts and th submission procss. All placmnts ar facilitatd by th Clinical Placmnt Coordinator Stacy Maximo in consultation with th Sit Coordinator. Placmnt assignmnt taks into considration an appropriat match btwn th studnt s nds and th clinical sit, as wll as th dat in which th Clinical Placmnt Packag is submittd by th studnt and procssd by th program. Thr ar Two Stps to complting and submitting your Clinical Placmnt Packag: STEP I Studnts will download th onlin Clinical Placmnt Packag (This can b found by going to Studnts hav th option of populating th filds using th fillabl pdf. Vrsion or by printing th documnt and populating th filds by writing th txt. You can also pick up a hard copy from th PHCNP Administrativ Offic locatd at POD 448. STEP II Studnts ar rquird to submit in-prson thir complt Clinical Placmnt Packag to Clinical Placmnt Coordinator Stacy Maximo. Not that faxd, scannd, or -maild vrsion will not b accptd no xcptions. In ordr to hav your packag procssd you will nd to -mail Stacy Maximo at to schdul a 15 minut in-prson appointmnt tim. You will nd to bring to your schduld appointmnt all compltd packag forms and supporting documntation. Th schduld appointmnt tim is usd to rviw your packag submission and to confirm that all rquird documntation has bn includd. Th dadlin dat for th program to rciv your complt Clinical Placmnt Packag is Thursday, August 11 th, Missing th submission dadlin dat will rsult in a dlayd placmnt assignmnt dcision. List of Rquird Forms & Supporting Documntation Th following is a list of th rquird clinical placmnt forms and supporting documntation that must b includd with your Clinical Placmnt Packag submission. Not that only original documnts will b accptd. Practic Information Rcord Form Practic Rquirmnt Form WSIB Form Polic Chck CPR Card Mask Fit Card Vaccination rcords and rcnt Bloodwork Signd and Datd Documnts Chcklist and Dclaration Stacy Maximo an updatd rsum (plas sav fil as Firstnam-Lastnam-Rsum) IMPORTANT: Plas submit your complt packag in prson to Stacy Maximo by Thursday, August 11 th,

4 Studnts that submit a complt packag by th dadlin dat will b givn full placmnt assignmnt considration Incomplt packags will not b considrd for procssing Plas mak a copy of this packag and all supporting documnts for your rcords PHCNP Crtificat Clinical Placmnt Trms & Conditions Clinical Placmnts typically commnc mid-to-nd of Sptmbr. Emphasis is on community and primary halth car sttings (.g. CHCs, GP offics); this is a gnralist program, thrfor clinical placmnt assignmnts rflct this foundational aspct. Plas mak sur that you hav rviwd and that you undrstand th following Clinical Placmnt Trms & Conditions: Stacy works at th univrsity part-tim; mails and voicmails will b rspondd to within thr businss days. Rgarding clinical placmnt gographical rstrictions (thr ar clar boundaris for th cntral rgion), studnts rsiding outsid of th GTA will not b guarantd a placmnt outsid of th Ryrson boundaris as dfind by th cntral rgion. Plas go to to viw th Rgional Map for th cntral rgion. All studnts ar xpctd to travl to sminars and clinical placmnts; LOCATION (whr you rsid) is not a factor - NO EXCEPTIONS. It is th studnt s rsponsibility to adapt thir prsonal schduls (i.. work and family), to accommodat th rquirmnts of th clinical placmnt; including th prcptor s schdul. You must b prcptord by at last on NP during th duration of th program. Th studnt s own workplac is not suitabl for clinical placmnts and will not b considrd NO EXCEPTIONS. Placmnts ar not subjct to studnt approval; if a studnt chooss to not accpt thir placmnt, th studnt will forfit th clinical placmnt. This action will jopardiz progrss in th program by prvnting continud nrollmnt in th clinical cours. Clinical placmnts ar non-ngotiabl; onc you ar placd thr will b NO CHANGES unlss thr ar xtnuating circumstancs that hav bn discussd with and approvd by th Program Dirctor. Nvr contact any agncy that is listd on th Cntral Rgistry Data Bas. Prospctiv agncis and prcptors that hav not first bn clard by Stacy ar not ligibl for placmnt considration. If you hav alrady mad contact and/or arrangmnts with a potntial prcptor, cancl thm and mail Stacy. Not all larning nds ar ncssarily mt at on particular clinical stting; othr opportunitis during th program will hlp facilitat with larning nds. Onc a placmnt is confirmd, and only whn contact information is forwardd to th studnt by Stacy, may th studnt contact th prcptor to arrang an intrviw or placmnt start-dat. 3

5 If you drop a cours with a clinical componnt or withdraw from th program, it is your profssional rsponsibility to communicat this with your prcptor, faculty, and NP offic staff. Th program rsrvs th right to rmov any studnt from placmnt whos prformanc dos not mt th xpctd standards of practic for a studnt at that lvl of th cours at that point in tim; and/or whr pattrns of bhaviour fail to dmonstrat succssful progrss towards mting th cours objctivs. This situation is not considrd to b unsaf practic unlss it rfrs to pattrns of bhaviour or an incidnt that puts slf, patint/clint and/or othrs at a risk that is both imminnt and of a substantiv natur. Th program is undr no obligation, in ths cass, to find an altrnativ placmnt. If, aftr discussions btwn studnt, prcptor and sit coordinator, it is dtrmind that a studnt s pattrns of bhaviour hav rsultd in th clinical practic agncy trminating th placmnt, th studnt may b advisd to drop th cours or if th studnt is dmd to hav jopardizd hr/his opportunity to complt th objctivs of th cours sh/h will rciv an F grad. Th agncy is not obligatd to mt with th studnt. 4

6 PHCNP Crtificat Powrpoint Undrstanding Clinical Placmnts 5

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12 PHCNP Practic Rquirmnt Rcord Plas complt th qustions blow: Your rspons to qustions #2 and #3 dos not guarant that you will b placd in thos aras of practic - thy ar simply usd as guidlins. 1. Plas indicat any prvious work xprinc (plas slct all that apply with an X ). Griatrics Womn s Halth Nurology Pdiatrics Mn s halth Cardiology Emrgncy Youth Oncology Intnsiv Car Unit Mntal Halth Gastrontrology Cardiac Car Unit Family Halth Tam Nphrology Trauma Community Halth Cntr Rspirology Urology Public Halth Rhabilitation Marginalizd Population Long Trm Car Mdicin Othr: 2. Slct which practic aras you would lik to b considrd for your clinical placmnt (plas slct all that apply with an X ). Griatrics Womn s Halth Nurology Pdiatrics Mn s halth Cardiology Emrgncy Youth Oncology Intnsiv Car Unit Mntal Halth Gastrontrology Cardiac Car Unit Family Halth Tam Nphrology Trauma Community Halth Cntr Rspirology Urology Public Halth Rhabilitation Marginalizd Population Long Trm Car Mdicin Othr: 3. Plas slct th following gographical ara that bst rprsnts th currnt city that you wish to b placd in with an X (plas slct all that apply with an X ). Cntral Toronto East Toronto Pl Rgion Durham Rgion North Toronto Wst Toronto Halton Rgion York Rgion Simco County Duffrin County Hamilton Rgion Watrloo Rgion Othr: 4. Plas indicat any larning nds that you may hav your clinical rotations: 11

13 5. If you hav a spcific clinical placmnt in mind that will mt your nds, plas provid th following: Organization Addrss Dscription of placmnt Prcptor Nam Contact Information Profssional Dsignation 6. Languags Spokn othr than English: 12

14 PHCNP Practic Information Rcord Last Nam: First Nam: Studnt # NOTE TO STUDENT AND HEALTH CARE PROVIDER (HCP) Ontario lgislation spcifis crtain survillanc rquirmnts for thos ntring into halthcar practic sttings. Th Nursing Program policy was dvlopd in accordanc with th communicabl disas survillanc protocols, spcifid undr th Public Hospitals Act, to mt th rquirmnts of our studnts placmnt sttings. This procss is ncssary to nsur that our studnts protct thir halth and safty, and th halth and safty of patints, visitors, mploys and othr studnts. Othr than th influnza vaccin, th compltion of this information is not optional, and all sctions must b compltd as outlind. Our placmnt partnrs hav th right to rfus studnts who hav not mt thir immunization standards 1. DIPHTHERIA, TETANUS, PERTUSSIS, POLIO Dat of last Diphthria Boostr : / / HCP Signatur: mm / dd / yyyy Dat of last Ttanus Boostr : / / HCP Signatur: mm / dd / yyyy Dat of last Prtussis Boostr : / / HCP Signatur: mm / dd / yyyy Dat of last Polio Boostr : / / HCP Signatur: mm / dd / yyyy 2. COMMUNICABLE DISEASES Not: laboratory vidnc is rquird to prov immunity for sctions blow; you must attach a copy of blood work. I. Masls, Mumps, Rublla (MMR) II. Laboratory vidnc of immunity or Documntation of 2 doss of MMR vaccin aftr 1 st birthday Variclla (Chickn Pox) Laboratory vidnc of immunity or Documntation of 2 doss of Variclla vaccin givn at last 4 wk apart 3. HEPATITIS B 1 st Dos Dat : / / 2 nd Dos Dat: / / mm/ dd/ yyyy Not: laboratory vidnc is rquird to prov immunity for Hpatitis B; you must attach a copy of blood work. 1 st Dos Dat : / / 2 nd Dos Dat: / / mm/ dd/ yyyy mm/ dd/ yyyy HCP Signatur: HCP Signatur : mm/ dd/ yyyy HCP Signatur: HCP Signatur : Laboratory vidnc of immunity and Documntation of Hpatitis B vaccination sris 1 st Dos Dat: / / HCP Signatur: mm/ dd/ yyyy Plas chck vaccination dos schdul: 2 nd Dos Dat: / / HCP Signatur: 2 Dos 3 Dos [ T y p a q u [ T y p a q u mm/ dd/ yyyy Studnts on 3 dos vaccination schdul must rciv at last 2 doss of th vaccin in ordr to attnd practic. Studnts should submit proof of final dos of sris as soon as it is rcivd. Hpatitis B chronic carrirs ar not 3 rd rquird Dos Dat: to disclos / / status to placmnt HCP Signatur: sits. mm/ dd/ yyyy 13

15 4. INFLUENZA VACCINE (Rcommndd) Influnza virus vaccin is availabl fr of charg from halth srvics in th fall or can b obtaind from your halthcar providr. Studnts ar ncouragd to submit vidnc of th vaccination. Not: if you know or suspct that you hav an allrgy to ggs or othr vaccination prsrvativs, plas discuss your options with your HCP. I undrstand that th influnza vaccin is not mandatory; howvr, if an outbrak occurs at my assignd agncy and I did not rciv th flu vaccin, I may b dnid accss to th facility, thus jopardizing succssful compltion of my practic. Studnt Signatur Dat 5. YEARLY TUBERCULOSIS SCREENING Not: If your stp 1 tst is positiv or hav tstd positiv anytim in th past, procd to sction B. Positiv skin tsts do not rquir TB skin tsting. Sction A: Mantoux Tst If thr is documntation of a prvious 2-Stp TB tst within th last 12 months, procd with 1-Stp tst only. Othrwis, if th 1 st tst is ngativ, a 2 nd tst is givn in th opposit arm at last 1 wk and no mor than 4 wks aftr th 1 st tst. You must b tstd for TB annually, and you must b covrd whil you ar in clinical practic. Stp 1 Tst Dat: / / Dat Rad: / / Induration: mm HCP Nam: mm dd yyyy mm dd yyyy Signatur : Stp 2 Tst Dat: / / Dat Rad: / / Induration: mm HCP Nam: mm dd yyyy mm dd yyyy Signatur : Sction B: CXR - only for positiv skin tsts: complt blow sctions AND attach a copy of chst x-ray rport: Chst x-ray Dat / / Rsult: Signs & symptoms of activ TB: Ys No [ mm dd yyyy Assssmnt Dat: / / mm dd yyyy HCP Nam: HCP Signatur: Not: Yarly chst x-rays ar not rquird unlss clinical status changs or advisd by HCP. You can thrfor attach a rport from a prvious chst x-ray takn within last 2 yars. Th HCP must still indicat and sign that thr ar no signs and symptoms of activ TB (abov). TB tsting should b compltd prior to th administration of any liv vaccins or 4 wks post rciving liv vaccin. SIGNATURE OF HEALTHCARE PROVIDER(S) Instructions: t t If you hav documntd on ths forms plas complt th sction blow or stamp and provid your signatur. Plas print clarly. Dat Nam of Halthcar Providr (plas print) Addrss (strt) Addrss (city & postal cod) Tlphon Numbr Signatur of HCP Titl (i.. MD, RN) Dat Nam of Halthcar Providr (plas print) Addrss (strt) Addrss (city & postal cod) Tlphon Numbr Signatur of HCP Titl (i.. MD, RN) Dat T y p a q u o f r Nam of Halthcar Providr (plas print) o m t h d o c u m n t o r Addrss (strt) Addrss (city & postal cod) Tlphon Numbr Signatur of HCP [ T y p a q u o f r o m t h d o c u m n t o r Titl (i.. MD, RN) 14

16 6. MASK FIT All studnts must b tstd and fittd for an appropriat mask (rspirator) in th vnt of flu (or othr airborn/droplt) outbrak. Cards must clarly stat th mask typ (modl) and siz. Plas nsur you carry your mask fit card at all tims during practic. Mask fit cards ar valid for 2 yars aftr th issu dat. Your Mask Fit card must b valid for th ntir tim that you ar in clinical practic. Plas prsnt your original Mask Fit card to Stacy Maximo with this form. 7. VULNERABLE SECTOR SCREENING (VSS) POLICE CHECK All studnts ar rquird to obtain a yarly VSS polic chck which must b valid for th ntir tim that you ar in clinical practic. You will nd to prsnt your original VSS polic chck as soon as you rciv it. STUDENTS CANNOT ATTEND PLACEMENT UNTIL SUBMSSION OF YOUR ORIGINAL VSS POLICE CHECK REPORT -- APPLY WELL IN ADVANCE. If you rsid in Toronto, you must com to th NP offic to complt a consnt form. Th compltd consnt form is thn maild to Polic Hadquartrs to apply for your VSS polic chck. Not: Toronto Polic Srvics can tak up to 8 wks or longr to procss your VSS polic chck. If you liv in othr municipalitis (.g. York Rgion, Pl Rgion), plas go dirctly to your polic hadquartrs. Plas chck th CPO wbsit for updats rlatd to th polic chck procss. Plas prsnt your original VSS polic chck to Stacy Maximo with this form. If you did not rciv your polic chck by th submission dadlin, plas submit as soon as you rciv it. If your polic chck is positiv, plas contact Luisa Barton ASAP at xt or at 8. CPR CERTIFICATION (HCP Lvl) Cardio Pulmonary Rsuscitation (CPR) Halthcar Profssional (HCP) lvl for placmnt purposs, your crtification must b HCP-lvl and xpirs on yar from th issu dat. CPR r-crtification is thrfor rquird on a yarly basis and must b valid for th ntir tim that you ar in clinical practic. Plas prsnt your original CPR card to Stacy Maximo with this form. 9. STUDENT DECLARATION Plas print out a copy of th Studnt Dclaration of Undrstanding Workplac Safty and Insuranc Board Covrag Unpaid Studnt Trains in Clinical Placmnts form. Mak sur you hav rad and signd a copy. This is to nsur that you hav undrstood that you ar covrd undr th WSIB whil you attnd your clinical practic. Plas prsnt a signd copy to Stacy Maximo with this form. 10. CNO ANNUAL REGISTRATION LICENCE Your CNO rgistration licns will b vrifid at Licns Numbr: Nam as it appars on your licns: To b compltd by Stacy Maximo: RN Entitld to practic: without rstrictions with rstrictions [ not ntitld [ to practic [ T y p a q u o t f T yt [ py T py a p qa uq a ou q to u to f t f 15

17 NOTICE TO STUDENTS COMPLETION OF THE PRACTICE REQUIREMENTS RECORD IS REQUIRED IN ORDER TO ATTEND PRACTICE. Whn you hav compltd ALL practic rquirmnts, submit this Practic Rquirmnts Rcords Packag togthr with all original documntation in prson to Stacy Maximo by 3pm on THURSDAY AUGUST 11 th, Do not fax, scan, or lctronically snd your rcords. Plas nsur you kp of all your documnts; th NP offic dos not kp copis of studnts immunization rcords, bloodwork, CPR, Mask Fit, or Polic chck and ar not rsponsibl if you misplac your documntation. Plas kp a copy of this Practic Rquirmnts Rcord; you may nd to prsnt it to your prcptor or to th agncy that you ar attnding. Plas b awar that you r VSS, CPR, and Mask Fit xpirs, and TB rquirs annual tsting. You may b rquird to rnw ths in th middl of clinical practic (dpnding on whn you got thm don). It is th studnt s rsponsibility to nsur thy know whn thy xpir and whn thy nd rnwal. You must b covrd throughout your clinical practic. Failur to comply with ths instructions will jopardiz your placmnt. Nam: Signatur: Dat: Th information on this form is collctd undr th authority of th Ryrson Univrsity Act and is rquird to procss your application for your practic placmnt cours. Th information will b usd in connction with placmnt ngotiations and communication with placmnt agncis. If you hav any qustions about th collction, us, and disclosur of this information by th Daphn Cockwll School of Nursing, plas contact Stacy Maximo via tlphon at xt. 4176, or via mail at or in prson in POD

18 PHCNP WSIB Studnt Dclaration of Undrstanding Workplac Safty and Insuranc Board (WSIB) Covrag for Unpaid Studnt Trains in Clinical Placmnts Studnt Dclaration of Undrstanding Studnts of halth scincs programs as idntifid by thir univrsity or collg ar ligibl for Workplac Safty Insuranc Board (WSIB) covrag of claims whil on unpaid placmnts rquird by thir program of study. Ministry of Training, Collgs and Univrsitis nsurs that studnts on work placmnts rciv WSIB insuranc covrag for injuris or disas incurrd whil fulfilling th rquirmnts of thir placmnt. Dclaration I hav rad and undrstand that WSIB covrag will b providd through th Ministry of Training, Collgs and Univrsitis whil I am on training placmnts as arrangd by th univrsity or collg as a rquirmnt of my program of study. I undrstand th implications and hav had any qustions answrd to my satisfaction. I agr to immdiatly rport any placmnt rlatd injury or disas to th placmnt mployr. Rlas of Information I undrstand that my prsonal information will b rlasd to th placmnt mployr in th vnt of a workplac injury or disas at th placmnt mployr s workplac during an unpaid placmnt. I undrstand that th Ministry of Training, Collgs and Univrsitis, th collg or univrsity and placmnt mployr will b rquird to rlas rlvant prsonal information with ach othr and to th WSIB. Studnt nam (print): Studnt signatur: Program/School: Dat: Parnt/Lgal Guardian s Signatur (for studnt lss than 18 yars of ag) Nam (print): Dat: Signatur: 17

19 PHCNP Clinical Placmnt Packag Documnts Chcklist Plas submit this compltd packag by August 11, 2015 to Stacy Maximo. Plas mak sur to includ th following: Practic Information Rcord Form Practic Rquirmnt Form Signd WSIB Dclaration Form Plas also bring th following Supporting Documntation to your schduld in-prson appointmnt: Polic Chck CPR Card Mask Fit Card Vaccination rcords and rcnt Bloodwork Signd and Datd Documnts Chcklist and Dclaration Plas mail Stacy Maximo an updatd rsum (plas sav fil as Firstnam-Lastnam- Rsum) IMPORTANT: Plas submit your complt packag in prson to Stacy Maximo by Thursday, August 11 th, 2016 Studnts that submit a complt packag by th dadlin dat will b givn full placmnt assignmnt considration Incomplt packags will not b considrd for procssing Plas mak a copy of this packag and all supporting documnts for your rcords By signing this form, I am dclaring that I hav rad and undrstand this Clinical Placmnt Packag in its ntirty, and that I am agring to th trms and conditions outlind in th documnt. Last Nam First Nam Studnt Signatur Dat Signatur of Stacy Maximo Dat 18

Remember you can apply online. It s quick and easy. Go to www.gov.uk/advancedlearningloans. Title. Forename(s) Surname. Sex. Male Date of birth D

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