PLACEMENT/STAGE REQUEST FORM
Post RN Diploma BSN Distance Program
SUMBIT FORM ELECTRONICALLY TO DEPRAC@UVIC.CA
IMPORTANT - READ THE FOLLOWING BEFORE COMPLETING THIS FILLABLE FORM
1) Placement request can only be submitted after consultation with the Practica Coordinator.
2) Respect placement request deadlines: Sept term due May 31st, Jan term due Sept 30th, May term due Jan 31st.
3) Information will be shared with the agency where a placement is requested.
4) Placement notifications will be sent to your UVic email address only. (if you do not have a UVic email go to UVic Systems)
5) * indicates a required field. An incomplete form may delay the processing of placement.
SECTION 1: STUDENT INFORMATION
Course Selection*: Select Course
What Term & Year are you requesting the placement for? *: Select Term/Year
Student: First Name*:
UVic Email*:
Last Name*:
Student Number*: V00
Home Phone*: (
Please check address regularly.
Place of Employment (Primary): Agency Name*:
Unit, Floor*:
Place of Employment (Secondary): Agency Name:
)
Cell Phone*: (
-
Role at Work*:
)
-
Employment Status*: Select Status
Place of Employment (Tertiary): Agency Name:
SECTION 2: PRACTICE PLACEMENT PLANNING
What is your first choice for your placement?
Agency Name*:
Agency Address*:
Unit, Floor*:
Agency Website*:
Statement of Intent for Placement:
1)
In 1-2 paragraphs, outline the following: Your area of interest; why you would like to do the placement on this unit; how does this align
with the course outline & with your educational and career goals? How has your professional background prepared you for this
placement?* (maximum 500 words)
2)
Describe the population of focus or interest (your interest) and what initiative or project you might be interested in participating in or
collaborating on during your practicum.* (maximum 500 words)
ONLY COMPLETE SECTION 3 OR 4
SECTION 3: PLACEMENT REQUEST WHERE YOU WORK (as noted in Section 1 – Place of Employment Primary)
Manager: First Name*:
Last Name*:
Job Title*:
Have you discussed this request with the Manager?*:
Field Guide: First Name*:
Last Name*:
Phone*: (
Yes
)
Work Email*:
-
No
Job Title*:
Have you discussed this request with a potential Field Guide?*:
Phone*: (
Yes
)
Work Email*:
-
No
SECTION 4: PLACEMENT REQUEST AT AN AGENCY WHERE YOU DO NOT WORK
Contact Person: Last Name*:
First Name*:
Job Title*:
Work Phone*: (
)
-
Work Email*:
FREEDOM OF INFORMATION/PROTECTION OF PRIVACY: The University of Victoria complies with the Freedom of Information/Protection of Privacy
legislation of the Province of British Columbia. Information collected on application forms and in student profiles/resumes is used in the normal course of
University operations in accordance with this legislation. By marking the box below, you authorize representatives of the University of Victoria, School of
Nursing to use and/or disclose your personal information in written and/or electronic transmission (name, nursing practice experience, learning needs/goals
and phone number) for the purposes of coordinating practice experiences.
While you have the right to restrict how we use this information, you must indicate this request in writing to the School of Nursing, and be advised that this
restriction may delay the processing of practice placement experiences. Please contact the Office of the University Secretary (usec@uvic.ca) if you have
questions or comments about freedom of information and protection of privacy.
By marking this box, I confirm that the information provided in this form is accurate and true, and I further ratify that I have read and agree
with the above declaration and the Freedom of Information/Protection of Privacy statement.
By marking this box, I confirm that I have read and understood the UVic School of Nursing practice requirements as per the UVic Calendar
and the practice information provided on the School of Nursing website.
Date: 2/6/2016
Placement/Stage Request Form – Post RN Diploma BSN Distance Program 2015