| * indicates mandatory field |
* First Name: |
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* Last Name: |
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* Email Address: |
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* School: |
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* Academic Standing: |
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Please Specify Other: |
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* Have you been at UHN for a clinical placement before? |
Yes
No |
If no, select an orientation date: |
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If yes, you know the eLearning user account that was issued to you? (begins w/UHNSN): |
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*Did you have access to the EPR system? |
Yes
No |
*Placement at which site? |
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* Department/Clinic: |
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HSPnet reference number (optional): |
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* Start Date: |
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* End Date: |
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*Mask Fit Information: |
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| If your make and model of mask is not listed contact the Placement Coordinator, velta.vikmanis@uhn.ca for further details. |
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| To receive IT support once you begin your placement, please answer ALL of the following questions: |
* What is your mother’s maiden name? |
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* What school did you attend in the 6th grade? |
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* What was the name of the street on which you grew up |
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| Please review the information that you have provided on this form. If you have completed all mandatory fields click on submit. You will receive information by email confirming your orientation date, time and location, as well as your eLearning user name and password. |
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| Any questions contact Velta.Vikmanis@uhn.ca (Please allow 5 business days for a response). |
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