Confirmed NUR461 Placements - Lawrence S. Bloomberg Faculty of Nursing

Confirmed NUR461 Placements
Agency/Clinic Name*
Agency Location
e.g. address, site name, branch, etc.
Agency Contact*
Contact details of professional practice/placement officers/managers
Agency Contact Title*
Agency Contact Phone*
Agency Email

Confirmation Emailexample@example.com
Agency Contact Email*

Confirmation Emailexample@example.com
Placement Agreement

NoYes
Student placements cannot be confirmed without a signed agreement. You cannot continue with this submission.
Agreement Expiry Date

MonthDayYear
Date
Type of Placement*
e.g. in-patient or unit name
Brief Description of Placement (2-3 sentences)*
Number of Students Accepted for Fall 2024*
Number of Students Accepted for Winter 2025*
Does your agency use HSPnet?

YesNo
Does this entry match what we have confirmed in HSPnet?

YesNo
What date was this confirmed by the agency?

MonthDayYear
Date
Explain the mismatch*
e.g. data entry error to be corrected, change to placement info, etc.
What date did you check HSPnet?

MonthDayYear
Date
Enter HSPnet reference number**
What date was this confirmed by the agency?

MonthDayYear
Date
Do you require students to do a pre-placement interview?*

YesNo
What additional follow up is required?*
Preceptor Name
Preceptor phone number
In the event of extended vacation/absence, who is the alternate contact?
Please provide the name, title, email, and phone number for the backup. This will assist us with communications related to on-boarding/orientation, changes, switches or cancellations.
Required On-boarding
Application forms/on-boarding documents

Cancelof
Comments
e.g. extra information such as orientation or limitation on days the students can work
Submission made by*
e.g. name, title
Should be Empty: