RPN to BScN Blended Learning Program Clearance Forms Package

Annual Renewal Submission Checklist

Renewal of nonacademic clinical placement requirements on an annual basis is mandatory for all students in the Blended Learning Program. Please read the following instructions carefully to ensure that all

requirements are competed accurately.

Incomplete packages will not be accepted.

KEEP YOUR ORIGINALS! Some agencies may require original documents and it is the students’ responsibility to supply them. Once you have completed all of the documents, you will add the completed Clinical Clearance Submission Checklist as the first page, and each subsequent page in the order on the checklist.

Document Submission Guidelines: Documents must be scanned, saved and emailed as one complete PDF file. Photos will not be

accepted. If you do not have access to a scanner you may go to a local printing shop (i.e. Staples) orlocal library to access one.

You must scan the complete document (both sides if applicable) and ensure the image is clear and theinformation is legible. For example most Police Vulnerable Sector Check (PVSC) documents are legalsize, therefore you must scan the full document as one complete file and not as two separatedocuments. It is not acceptable to scan the top and bottom of documents.

Documents must be ordered 1-8 according to the Clinical Clearance Submission Checklist

Renewal Submission Deadline December 1st

It is strongly encouraged that all required documentation be submitted by November 1 for the December 1st

deadline. Submitting documentation early will allow time for the School of Nursing to review your submission prior to the deadline. Documentation submitted at the last minute that is incomplete, out of date, or missing will not allow sufficient time for the revision. Any documentation received after the deadline will NOT be accepted nor any additional time given. Failure to meet the clearance requirements by the due date will result in your removal from any clinical planning for the next 3 semesters.

Required Documentation

Please review the following pages for specific instructions on each item required to complete your clearance package for clinical placement. If you have additional questions or concerns, please contact our office as early as possible to request clarification.

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Nonacademic Clinical Placement Requirements Instructions and Additional Information

All Forms can be found at www.nipissingu.ca/blendednursingforms or by clicking the title for each form**

1. Clinical Clearance Submission Checklist** You must ensure that all documents listed on the checklist are included in your package submission or you will not be cleared.

2. RPN to BScN Blended Learning Program Clinical Clearance Declaration** Read the declaration in its entirety. Sign and date the declaration acknowledging you understand and agree.

3. School of Nursing Contact Form** Fill in all information required on the form. You must also update any address changes in WebAdvisor directly.

4. Consent to Release Personal Information Form** Read the form in its entirety. Complete the required information, sign and date acknowledging you understand and agree.

5. CPR ‐ Level "C" or "HCP" It is the responsibility of the student to obtain a valid annual CPR Level “C” or “HCP” certificate to be

cleared for clinical placement. The cost of this certification and recertification is the responsibility of the

student. The School of Nursing does not accept online certification for CPR, as the training session must

have a hands on component delivered by an approved health care training agency. Recertification of

CPR is required on an annual basis and must not expire before the next clearance period. CPR

certificates are only considered valid by the School of Nursing for one year from the date of issue,

regardless of the expiry date provided on the card or the policy at your place of employment.

6. N95 Mask Fit It is the responsibility of the student to be Mask Fit tested upon admission to the program. The scheduling and cost (if any) of this testing is the responsibility of the student. Failure to present a valid mask fit card/ certificate will result in denial of access to practicum placement. Mask Fit testing is valid for 2 years from the date of testing, regardless of the expiry date provided on the card or the policy at your place of employment. Mask fit testing must not expire prior to the next clearance period.

7. Police Vulnerable Sector Check (PVSC) Your PVSC must have a request date between September 1-31. Requests dated outside of this timeframe will not be given special consideration if not received by December 1 due to delayed processing. Processing times vary depending on region so you must contact your local police department ASAP to inquire about their turnaround time to ensure you are able to meet the clearance deadline. Police Vulnerable Sector Checks are only considered valid by the School of Nursing for one year from the date of issue. Some placement agencies have different “dates of validity” and student may be required to request and submit a second PVSC if required by the agency. Your local police authority may require a representative of the School of Nursing to complete a "Consent to Disclosure" form or letter. A personalized letter has been prepared and sent to your Nipissing University email by the clinical placement team, if the police department requires additional information please contact our office.

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8. WHMIS You must self-enroll in WHIMIS. You must select the course named WHMIS Training for student workers, student researchers, thesis students, volunteers, etc. Please follow the directions included in the package.

9. Communicable Disease Screening Renewal Form (CDSF)** Please see CDSF for further information and instructions. NOTE: Information is only to be submitted using the CDSF. NO additional forms (i.e. medical documentation, lab results, etc.) will be accepted.

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Annual Renewal Clinical Clearance Package Checklist

Student Name:

Student #:

Date of Submission:

Program: RPN to BScN Blended Learning Program

Number of pages scanned:

Attached (please check off):

o 1. Clinical Clearance Submission Checklist

o 2. RPN to BScN Blended Program Clinical Clearance Declaration

o 3. School of Nursing Contact Form

o 4. Consent to Release Personal Information Form

o 5. CPR – Level “C” or “HCP”

o 6. N95 Mask Fit

o 7. Police Vulnerable Sector Check (PVSC)

o 8. WHMIS Certificate

o 9. Communicable Disease Screening Renewal Form

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RPN to BScN Clinical Clearance Declaration Letter

I have reviewed the information and instructions Name (please print)

outlined on the Clearance Forms package in its entirety.

As a means of personal verification, I understand that all documents and correspondence must be sent to and received by my Nipissing University Community email account.

To the best of my knowledge, the package I am submitting is complete, all documents are

authentic and have not been falsified or altered. I understand that if I submit false, misleading,

misrepresented, altered, omitted or forged documentation that I am knowingly committing

academic dishonesty and will be subject to the consequences associated with this infraction.

Consequences of academic dishonesty include, but are not limited to; receiving a 0 or U in the

course, suspension from the university, special conditions for readmission, expulsion from the

program, and reporting the incident to the College of Nurses of Ontario (for more information,

please consult the Student Handbook and academic calendar).

I agree that I was given the opportunity to submit my documentation for review in advance and

I understand that any documentation received after the deadline will not be accepted. I

understand that if I choose to submit my documentation after the suggested submission date

and it is not complete and/or correct, no additional time will be granted for follow up.

I understand that failure to submit a correct and complete package by the deadline will result

in my inability to participate in clinical for the next semesters.

By signing below I agree to the above information.

Signature Date

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RPN to BScN Blended Learning Student Contact Information Sheet

Name: ______________________________________________________________________

Student ID #: _______________________________________________________________________

Phone Number(s): _______________________________________________________________________

_______________________________________________________________________

School Email Address:

_______________________________________________________________________

Home Address: _______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Emergency Contact: _______________________________________________________________________

Contact Phone Number: ______________________________________________________________________

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School of Nursing

CONSENT TO RELEASE PERSONAL INFORMATION

I hereby provide my permission to Nipissing University to release my personal information for the purposes of financial sponsorship and clinical placement. This personal information includes the following:

i) my student fees / awards account at Nipissing University ii) my health and criminal records submitted to Nipissing University iii) my clinical placement requirements determined by Nipissing University

This release will be in effect until my completion of or withdrawal from my flexible learning program (such as the RPN to BScN Bridging or SPP program), or written notice is received by Nipissing University from me indicating that consent has been rescinded.

As previously indicated, I understand that when my personal information is released it is for the purpose of securing sponsorship for the payment of fees and/or arranging clinical placements throughout my program. My personal information can therefore be released to my human resources department and health care agencies as applicable.

Last Name: (please print)

First Name: (please print)

Student ID: Date of Birth: (mm/dd/yy)

Program: RPN-BScN Blended Learning Location/Employer: (please print)

(mm/dd/yy) Signature of Student Date

Protection of Privacy The information on this form is collected under the authority of the Nipissing University Act, 1992. It is related directly to and needed by the University to support your fee sponsorship and clinical placements through Nipissing University’s School of Nursing. The information will be used to process your sponsorship and clinical placements and will be disclosed to the staff in Student Financial Services and School of Nursing. If you have any questions about the collection, use, and disclosure of this information please contact the School of Nursing, Nipissing University, 100 College Drive, North Bay, ON P1B 8L7, 705.474.3461 ext 4567.

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I n t e r n e t : w w w . n i p i s s i n g u . c a

Revised March 2014 09/18/2017

How to Self-enroll into the BlackBoard WHMIS 2015 Course 1. Go to the Nipising University Health and Safety WHMIS webpage.

http://www.nipissingu.ca/departments/human-resources/health-and-

safety/training/Pages/WHMIS%202015.aspx

2. To access the WHMIS 2015 training course, click on the appropriate link under the ‘Online Training

Courses available anytime (self-enrollment through BlackBoard)’. See area boxed in red below.

3. When the link is clicked, you will be taken to the BlackBoard Log-in Screen (please note that the login

screen may not be exactly as shown below). Enter your credentials (web-advisor username and

password) and click enter.

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4. If you haven’t enrolled in the course before, you will receive the screen below. If you have enrolled

in the course, skip to step 6. To enroll into the course, click the ‘Enroll’ button on the left-side

information bar (red arrow).

5. You will be presented with a self-enrollment confirmation screen. Click the ‘Submit’ button to

confirm enrollment into the WHMIS 2015 course (red circle below).

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6. Once confirmed, you will be presented with confirmation of enrollment. Click the ‘OK’ button to

access the course landing page (red circle below).

7. You are now ready to start the course. Click on the ‘WHMIS Training Module’ (highlighted with a red

box) to open a new pop-up window in your browser and begin the course. Please note: you

may need to disable your browser’s pop-up blocker to allow the course to run in a new browser

window. If you require assistance in how to disable pop-up blockers, please contact the Technology

Services Help Desk at extension 4342.

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RPN to BScN Blended Learning Program Communicable Disease Screening Renewal Form

Dear Student,

The RPN to BScN Blending Learning Program includes clinical placements as an essential component of the program. In order to protect yourself and the patients you will be interacting with, you must complete all required immunizations upon admission and annually as indicated. You may also be required to update any necessary immunizations during your enrollment in the program. It is your responsibility to carefully review the following instructions and ensure that you comply with all of the requirements.

Important Information

Failure to submit a signed and duly completed Communicable Disease Screening Form to the School of Nursing will result in ineligibility to register for clinical courses. Please ensure that your healthcare provider understands that every page and section MUST be completed in full and that a signature from a licensed healthcare provider is also required on each page. Failure to comply may lead to repeat testing/immunization. Incomplete documents will be discarded.

The following requirements may differ from your workplace, but these are the requirements that are necessary for the School of Nursing at Nipissing University.

Agencies have reserved the right to refuse access to students who do not meet their clinical placement requirements. Agencies may have additional requirements that are separate from the School of Nursing requirements and additional items may need to be completed if requested.

Sections can be filled out either by the student and then approved and endorsed by a qualified healthcare provider OR completed in full by a licensed healthcare provider (Physician, Nurse Practitioner, Registered Nurse or Registered Practical Nurse) and signed, the designation of the healthcare provider must also be included.

The completed form is to be scanned in a PDF format as part of your clinical clearance package (see instructions outlined on the Clearance Form Package) and emailed to clinicalclearance@nipissingu.ca Please note that you must submit all documents as per the guidelines in order for your package to be reviewed, faxes or mailed hard copies will NOT be accepted. Questions regarding these instructions, the form and/or the requirements, should be directed to the Clinical Placement Coordinator at 705-474-3450 x4661.

Kind Regards,

Clinical Placement Team 1 of 3

Revised August 2017

STUDENT NAME: STUDENT NUMBER: _

DATE OF BIRTH:

Student Authorization: I give my consent that the information on this form may be shared as required with Nipissing University, Clinical Faculty,

Administrative/Support Staff and Placement Agencies.

SIGNATURE: DATE:

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2 of 3 Revised August 2017

Student Name:

Student Number:

INSTRUCTIONS IMMUNIZATION/SEROLOGIC STATUS

TUBERCULOSIS Tuberculin Skin Test (TST)

Please provide proof of you annual one-step Tuberculin Skin Test (TST).

The test must be dated between September and November 1 of each year.

Positive Result: If either TST (2-step or 1-step) is positive, the student will be required to submit the following documentation included with their Communicable Disease Screening form (Note: both documents 1 & 2 are required):

1. Copy of recent chest x-ray report (x-ray must be less than 1 year old)

*AND* 2. Annual TB Surveillance Letter. A copy of this letter

can be found at: www.nipissingu.ca/blendednursingforms

Future TSTs are not required but the TB Surveillance Letter must be completed and submitted on an annual basis as part of your renewal clearance package.

A repeat chest x-ray is only required if there has been a risk of exposure.

One Step Tuberculin Skin Test (TST)

Date Given: (dd/mm/yy) Date Read: (dd/mm/yy)_

Result/Induration: _mm

Signature & Designation:

□ Student has a history of a positive TST. Date of positive TST: **Please include x-ray and TB surveillance letter

Licensed Healthcare Provider Declaration:

I Confirm that the information provided on this form is correct:

Name: Date:

Signature: Designation:

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3 of 3 Revised August 2017

Student Name:

Student Number:

INSTRUCTIONS IMMUNIZATION/SEROLOGIC STATUS

TETANUS/DIPHTHERIA Students must show proof of vaccination for Tetanus & Diphtheria every 10 years. It will be the responsibility of the student to ensure that these boosters remain up to date after admittance into the RPN to BScN Blended Program.

To ensure Tetanus & Diphtheria vaccination is up to date, students must submit proof of vaccination annually for review.

Primary Vaccine or Booster received within the last 10 years:

Vaccine Name: Date (dd/mm/yy)_

Licensed Healthcare Provider Declaration:

I Confirm that the information provided on this form is correct:

Name: Date:

Signature: Designation:

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