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

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

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Date:
Clinical Educator Status Appointment Application
In accordance with the process for the status appointment of Clinical Educators, please complete and submit this
application to the Clinical Education Office at Michener clinicaleducation@michener.ca.
PART I -CLINICAL EDUCATOR INFORMATION
Prefix: __________ Name: _______________________________________________________________________
Clinical Site: ___________________________________________________________________________________
Position: ____________________________________ Department: ______________________________________
E-Mail Address: ________________________________________________________________________________
Phone Number: _________________________________ Fax Number: ___________________________________
Professional Certification(s): ______________________________________________________________________
Michener Program: ____________________________________ Number of Years Teaching: __________________
PART II - ACKNOWLEDGMENT
I recognize and agree to fulfil the responsibilities required by the status-only appointment as Clinical Educator:
Excellence in clinical instruction
Evaluation by s tudents
Adherence to clinical course outlines
Commitment to professional development in interprofessional education
Direct contribution to the clinical student attainment of clinical competencies, as identified by the Clinical
Coordinator
Completion of an Annual Progress Report to maintain the status appointment as Clinical Educator
I grant permission to have my name and photograph published in future Michener publications and on Michener s
website. ☐ Yes ☐ No
Clinical Educator Signature: ______________________________________ _______________________________
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.
Clinical Coordinator / Supervisor Signature: _____________________________________ Date: ______________________
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Clinical Educator Status Appointment Application PART I -CLINICAL (The Michener Institute of Education at UHN)

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Completed 10 February 2021

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