Fillable G Cert Diab Ed Clinical Placement Form (James Cook University of North Queensland)

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G Cert Diab Ed Clinical Placement Form (James Cook University of North Queensland)

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Clinical Placement Form GCertDiabEd pg 1_Draft v1.1 Page 1 of 2
1) The Graduate Certificate of Diabetes Education requires you to complete supervised clinical placement
with a credentialed diabetes educator.
2) You are required to:
a) source an organisation to host your clinical placement.
b) provide the details of the organisation that is hosting your placement and the Preceptor who will be
supervising your placement on page 2.
c) show evidence that your Preceptor will support your completion of the clinical placement components
of the course. Confirm that your preceptor meets the guidelines the JCU preceptor criteria outlines.
Please note it is acceptable that your Preceptor is NOT an ADEA Credentialed Diabetes Educator (CDE),
however if this applies then exclusion criteria may apply and a Preceptor CV will need to be forwarded
to your course coordinator for review and approval. It is essential that this section on page 2 be signed
by the Preceptor before you submit this form.
3) Please complete page 2 and submit this document with your online application to the Graduate
Certificate of Diabetes Education.
4) Upon acceptance into the course, the James Cook University Clinical Placement team and
Course Coordinator will contact the organisation hosting the placement to issue a JCU Student
Placement Agreement.
a) A JCU Student Placement Agreement between your host venue and the University must be in place
before you can commence your placement even if your host venue is also your employer. The
University undertakes this process for you and we ask that you submit this form with your
application to the course to ensure that we can conduct these negotiations before you are due to
commence your placement(s). The University will advise you if you need to delay your placement
whilst a JCU Student Placement Agreement is negotiated and advise you when you are able to
commence your placement once it is in place.
5) The JCU Clinical Placement team must receive evidence that you comply with all of the Pre-
placement Requirements as outlined on the Professional Experience Placement website before a
placement can be undertaken. Please refer to: https://www.jcu.edu.au/professional-experience-
placement
GRADUATE CERTIFICATE OF DIABETES EDUCATION
Clinical Placement Requirements
Please complete page 2 and submit with your online application.
Clinical Placement Form GCertDiabEd pg 2 DRAFT v1.1 Page 2 of 2
1. STUDENT DETAILS
Full Name
Position title
Organisation hosting placement
Organisation postal address
State
Postcode
2. PRECEPTOR DETAILS
Full name
AHPRA registration number
Position title
Email
Telephone
Dates and Times of Student attendance (if known)
PLEASE INDICATE WHETHER YOU ARE AN ADEA CREDENTIALED DIABETES EDUCATOR.
- I confirm that I am an ADEA Credentialed Diabetes
Educator; and
- I confirm that the required support will be provided to the
student to undertake the clinical placement components of
the course within this workplace.
- I confirm that I am NOT an ADEA Credentialed Diabetes
Educator; and
- My CV is attached; and
- I confirm that the required support will be provided to the
student to undertake the clinical placement components of
the course within this workplace.
Signature
Date
Clinical Placement Form
Graduate Certificate of Diabetes Education
Please complete this form and submit with your online application to apply
for Graduate Certificate of Diabetes Education.
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G Cert Diab Ed Clinical Placement Form (James Cook University of North Queensland)

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Completed 21 July 2020

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