The personal information requested on this form is necessary to the proper administration of a lawfully authorized activity and, as applicable, is collected in accordance with subsection 38(2) of the Freedom of Information and Protection of Privacy Act (FIPPA), R.S.O. 1990, c.F.31 as amended. Questions about this collection should be directed to 416-785-2500 ext. 2518. The information provided will be used for Baycrest administrative purposes including external reporting by the government. I understand that personal information collected on this form will be held electronically on a third party server that is outside of Baycrest. Information regarding this third party server is available through the Department of Academic Education.

Nursing Student/Instructor Registration

Personal Information
First Name
MI
Last Name
Suffix
Profession/Discipline
Student Type
Gender
Home Address
City
Province
Zip Code
Home Phone
Cell Phone
E-mail Address

In case of Emergency, who may we contact?
Contact name
Relationship
Home Phone
Cell Phone
E-mail

Educational Information
School/Educational Institution
Year/Semester
Educational Program
Have you been a student at Baycrest before?
If you have been a student at Baycrest please enter date below

Placement at Baycrest
Your Start Date
Rotation End Date
Unit/Service Area You Are Currently Placed
Baycrest Supervisor
Academic Supervisor
Number of Weeks
Days per week
Hours per Day

STUDENT AGREEMENT OF RESPONSIBILITY


Baycrest and your educational institution have a contractual agreement that governs your placement experience at Baycrest. In addition to that, there are specific responsibilities you must be aware of and in agreement with before you may begin your placement at this facility.

Please indicate that you understand and agree to the following statements by signing below:

1. All the information that I have provided on the reverse of this document is accurate.

2. I agree to abide by all regulations, policies and procedures that govern Baycrest, and understand that copies of these are available to me on the Baycrest intranet, and through my Baycrest Supervisor.

3. I understand that members of the Baycrest staff are the final authority for all aspects of patient care and for the integration of the educational program into Baycrest.

4. I acknowledge that any client at any time may decline to have me involved in their care, based on my status as a student.

5. I understand Baycrest at no time will accept responsibility for loss or damage to my personal property including motor vehicles parked or driven on Baycrest premises.

6. I understand that Baycrest may terminate this agreement at any time should my conduct or performance be deemed unacceptable. Except in extraordinary circumstances, such a decision would not be made without first consulting my educational institution and me.

7. I will at all times practice within the scope of my knowledge and skill, and I will request and accept appropriate supervision in my provision of patient care.

8. I consent to the collection and use of my personal information on this form by Baycrest for administrative purposes including external reporting as required by the government. I understand that personal information collected on this form will be held electronically on a third party server that is outside of Baycrest. Information regarding this third party server is available through the Center for Education and Knowledge Exchange in Aging Department of Organizational Effectiveness within Human Resources.

9. I agree to wear the identification badge assigned to me at all times during my placement at Baycrest, and to return it to Baycrest when I have completed my placement(s).




SIGN-OFF LETTER

Introduction

Baycrest and its representatives are obligated to meet the requirements of the Occupational Health and Safety Act and Regulations for Health Care and Residential Facilities. Failure to do so may lead to the Ministry of Labour issuing individual and/or organizational fines and the closure of Baycrest until that time when the requirements have been fulfilled.

A) Generic topics that are common to all organizations.
We anticipate that you have obtained in-depth information about the following key topic. Please confirm this by signing this form.

i. Workplace Hazardous Information System (WHMIS)

B) Baycrest- specific topics: these are either unique to Baycrest or have been customized to our organization.
We require you to review the attached material on these topics and then sign below indicating you have completed this review.

ii. Client Privacy and Confidentiality

iii. Appropriate use of Internet and E-mail

iv. Emergency Codes

v. Infection Prevention and Control (IPAC) Education

vi. Jewish Life at Baycrest

vii. Fire Safety

viii. Violence in the Workplace
[as our policy on Violence in the Workplace is under review, we are presently adhering to our current policy on Abuse of Staff and Volunteers by Clients, Their Families, Private Practitioners, Personal Companions and Visitors]








STUDENT IMMUNIZATION AGREEMENT

To comply with the Ontario Occupational Health and Safety Act and OMA/OHA protocols under Regulation 965 of the Public Hospitals Act, students (working in a hospital environment) are required to have the immunizations listed below; be free from active tuberculosis; and participate in baseline skin testing. Given our patient population, we strongly recommend that all students have an influenza vaccination. Any student who refuse to take a flu shot will be required to wear surgical mask at Baycrest during the flu season. If an outbreak occurs, students who have not been vaccinated will not be able to continue their placement until they have finished a course of Tamiflu. Prophylaxsis.

NOTE: Any costs associated with the completion of this form are the responsibility of the student/educational institution.
Required:
  • Measles, Mumps, Rubella/Rubeola (German and Red Measles)
  • Varicella(ChickenPox)
  • Tuberculosis (TB) Status

    Prior to placement, students are required to have a documented 2-step tuberculosis skin test done prior to start date. This involves the planting of a tuberculin skin test in the forearm, having it read by a licensed Healthcare Provider 2-3 days later and if negative, the process will be repeated in the other arm 1-3 weeks later.

    The 2-step skin test identifies the truly positive skin test. It is essential to have accurate baseline information at the beginning of your placement as this is the comparison that is used in the event of an exposure.

    Not mandatory but recommended for the protection of the student:
  • Tetanus/Diphtheria
  • Influenza Vaccine
  • Hepatitis B Vaccine

    Proof may take the form of
    1. Immunization Certificates
    2. Antibody Titre results
    3. Registration in a program where confirmation of 1& 2 are available upon request.
  • I acknowledge that I have read the Student Agreement of Responsibility
    Click on the Core Curriculum and review prior to checking the "acknowledgement" box.
    I acknowledge that I have read the Core Curriculum and Sign-Off letter
    Check the Completed Immunization
    I acknowledge that I have completed the required immunization and can show proof if asked

    Criminal Reference Check/Vulnerable Sector Screening Report (CRC/VPS)

    Students and trainees are required to submit proof of their CRC/VPS report



    If you have not yet received proof of your CRC/VPS, please read and agree to the terms below.

    1. I have been unable to obtain documentation for my CRC/VSS as required for clinical/field placement in time for the term despite my best efforts to do so.

    2. I have provided proof of my efforts and related communication with the Police Department to my Dean/designate.

    3. I know of no reason why I will not eventually receive a clear CRC/VSS or not be eligible for clinical/field placement on this basis.

    4. I will provide my program coordinator and the department of Academic Education Room # 2N04 with the CRC/VSS documentation immediately upon receiving it.

    I understand that failure to provide documentation once I receive it or receipt of a CRC/VSS that is not clear may result in immediate withdrawal from the clinical/field placement. Students who do not have a satisfactory result will be considered on a case by case basis, in consultation with the educational institution.

    Misrepresentation on the signed declaration will be cause for the immediate termination of the clinical/field placement.


    MASK FIT TEST
    You are required to be mask fitted prior to commencing your placement at Baycrest. Please check mark the mask you have been fitted with.
    Mask Fit Test
    Date fitted
    Date expire
    Other Mask Fit
    Note: If you have been fitted with a mask other than the ones listed above.
    Please note that you have to bring the mask fit card with you to be re-fitted at Baycrest.
    I agree to provide proof of the mask fit card selected above on my first day