Fillable Clinical Coordinator Status Appointment Application PART I -CLINICAL (The Michener Institute of Education at UHN)

Fill Online, Printable, Fillable, Blank Clinical Coordinator Status Appointment Application PART I -CLINICAL (The Michener Institute of Education at UHN) Form

Use Fill to complete blank online THE MICHENER INSTITUTE OF EDUCATION AT UHN pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Clinical Coordinator Status Appointment Application PART I -CLINICAL (The Michener Institute of Education at UHN)

On average this form takes 5 minutes to complete

The Clinical Coordinator Status Appointment Application PART I -CLINICAL (The Michener Institute of Education at UHN) form is 1 page long and contains:

  • 2 signatures
  • 2 check-boxes
  • 12 other fields

Country of origin: CANADA
File type: PDF

Use our library of forms to quickly fill and sign your The Michener Institute of Education at UHN forms online.

BROWSE THE MICHENER INSTITUTE OF EDUCATION AT UHN FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
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 clinicaleducation@michener.ca.
PART I -CLINICAL COORDINATOR INFORMATION
Prefix: __________ Name: _______________________________________________________________________
Clinical Site: ___________________________________________________________________________________
Position: ____________________________________ Department: ______________________________________
E-Mail Address: ________________________________________________________________________________
Phone Number: _________________________________ Fax Number: ___________________________________
Professional Certification(s): ______________________________________________________________________
Date of Original Appointment: ___________________________________________________________________
PART II -ACKNOWLEDGMENT
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: _______________________________
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Clinical Coordinator Status Appointment Application PART I -CLINICAL (The Michener Institute of Education at UHN)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 10 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document