Clinical Coordinator Status Appointment Application
In accordance with the process for the status appointment of Clinical Coordinators, please complete and submit this
application to the Clinical Education Office at Michener
Prefix: __________ Name: _______________________________________________________________________
Clinical Site: ___________________________________________________________________________________
Position: ____________________________________ Department: ______________________________________
E-Mail Address: ________________________________________________________________________________
Phone Number: _________________________________ Fax Number: ___________________________________
Professional Certification(s): ______________________________________________________________________
Date of Original Appointment: ___________________________________________________________________
I recognize and agree to fulfil the responsibilities required by the status-only appointment as Clinical Coordinator:
Liaison with Michener for the placement of clinical students
Direct communication link between the clinical site at the department level and the Clinical Education Office
and clinical liaison officer at Michener
Overall supervision of the education and evaluation of clinical student(s)
verall attainment of all clinical competencies
Annual identification of staff members assigned to be clinical educators
Completion of an Annual Progress Report to maintain the status appointment as Clinical Coordinator
I grant permission to have my name an
website. Yes No
Clinical Coordinator Signature: ______________________________________ Date: _______________________________
As validated by my signature below, I support this application and believe that this individual possess the appropriate
knowledge and skills for the required administrative and coordination functions.
Manager / Supervisor Signature: _____________________________________ Date: _______________________________
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