CNO



Evidence of Language Proficiency ─ righttop00Education FormCollege of Nurses of Ontario101 Davenport Rd., Toronto, ON M5R Telephone: 416 928-0900Toll-free (Canada): 1 800 387-5526Fax: 416 928-6507IMPORTANT: The evidence you provide in this form will be used by the College of Nurses of Ontario (CNO) to determine if the applicant can practice and communicate and understand effectively as a nurse. You must have/had direct knowledge and contact with the applicant and must provide examples of how they demonstrate language proficiency in listening, reading, writing, and speaking in English or French relevant to the last two years. Making a false or misleading representation or statement could result in the cancellation of the application(s) for registration and/or any certificate of registration that may be issued. CNO may contact the school as a source to validate the information provided on this form.IMPORTANT: The evidence you provide in this form will be used by the College of Nurses of Ontario (CNO) to determine if the applicant can practice and communicate and understand effectively as a nurse. You must have/had direct knowledge and contact with the applicant and must provide examples of how they demonstrate language proficiency in listening, reading, writing, and speaking in English or French relevant to the last two years. Making a false or misleading representation or statement could result in the cancellation of the application(s) for registration and/or any certificate of registration that may be issued. CNO may contact the school as a source to validate the information provided on this form.Please review the Privacy Policy at privacy to understand how your personal information will be used. How to complete this form:Step 1: The applicant should complete section 1 and send the form directly to the school. Note: Applicant should remember to fill out their name and application number in the space provided at the bottom of each page.Step 2: The school should complete section 2.Step 3: The school should prepare a separate document detailing the evidence information CNO requires as listed in section 3.Step 4: The school should mail the form and documents in a sealed letterhead envelope to CNO using the mailing address provided at the top of this form. 1. APPLICANT’S INFORMATION FORMTEXT ?????53340023812400412750023812400 FORMTEXT ?????53340023812400412750023812400First nameLast Name FORMTEXT ?????53340023812400412750023812400 FORMTEXT ?????53340023812400412750023812400Application numberDate of Birth (yyyy-mm-dd)As part of my application to become a nurse in Ontario, CNO is requesting that your organization provides information about my education that proves that I am proficient in the English or French language. I hereby give you (my previous and/or present school) consent to provide any and all information in your possession to CNO regarding my nursing education. This shall constitute your legal authority to provide the information and any other information which CNO shall request which may, in any way, be relevant to my application.53340023812400412750023812400 FORMTEXT ?????53340023812400412750023812400Applicant’s signatureDate (yyyy-mm-dd) 2. SCHOOL’S INFORMATION FORMTEXT ?????53340023812400412750023812400 FORMTEXT ?????53340023812400412750023812400Name of schoolTelephone number (include country code): FORMTEXT ?????53340023812400412750023812400 FORMTEXT ?????53340023812400412750023812400AddressCity FORMTEXT ?????53340023812400412750023812400 FORMTEXT ?????53340023812400412750023812400Province/StateCountry 3. EVIDENCE INFORMATIONProvide evidence of education where English or French was the primary language used for communication in listening, reading, writing and speaking. The education experience must have been completed within the last two years. FORMTEXT ?????53340015049400Program name FORMTEXT ?????53340023812400412750023812400 FORMTEXT ?????53340023812400412750023812400Start date (yyyy-mm-dd)End date (yyyy-mm-dd)The focus of the education was: FORMCHECKBOX Nursing FORMCHECKBOX Non-NursingConfirm if the applicant completed a: (check all that applies) FORMCHECKBOX Clinical practicum FORMCHECKBOX placement FORMCHECKBOX co-op FORMCHECKBOX labHow many hours did the applicant complete in an actual supervised clinical practicum/placement/co-op? FORMTEXT ?????Where was the supervised clinical practice completed? FORMTEXT ?????How many hours did the applicant complete in a simulation lab? FORMTEXT ?????What is the format of the lab (i.e. SimMan, Standardized Patients)? FORMTEXT ?????How many hours did the applicant obtain through Prior Learning Assessment Recognition (PLAR)? FORMTEXT ?????Please attach the following information to this form and send directly to CNO The applicant’s academic transcript and course descriptionsLetter(s) of reference from teacher(s), preceptor(s) or someone who supervised the applicant in practicum, placement or co-op, and who can provide an evaluation how the applicant uses/used language abilities in listening, reading, writing and speaking (including examples) in English and French.I confirm that the evidence attached to this form is accurate and relates to the applicant’s education within the past two years. FORMTEXT ????? FORMTEXT ?????53340023812400412750023812400School contact name & titleSchool contact name FORMTEXT ?????53340023812400412750023812400Signature & Date (yyyy/mm/dd)Email address ................
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