May 29th, 2012
• Please complete the following page to enable Dovetale training scheduling.
• This form is to be returned at least 6 weeks prior to the start of the learner placement. Your placement will not happen if we don’t have this form in the timeframe identified.
• You will be notified of your training by email. You must attend training before the start of your placement or shortly after starting placement.
• Complete the first page of the form. Email the whole document to Peggy Bosanac pbosanac@stjoes.ca.
Student-please complete:
1. Legal First Name:
2. Legal Last Name:
3. School email address:
4. School:
5. School student ID #:
6. Program at School:
7. Placement Role:
8. St. Joseph’s Supervisor Name:
9. St. Joseph’s Clinical Program:
10. St. Joseph’s Program Location:
11. Start Date of Placement:
12. End Date of Placement:
Thank you,
Peggy Bosanac, PT
Academic Placement Coordinator for Health Professionals with the exception of Physicians and Nurses
905-522-1155 Ext 32264
Fax: 905-521-6135
pbosanac@stjoes.ca
Supervisor-please complete this page and return both pages of the form to Peggy Bosanac.
13. St. Joseph’s Program Location: ?Charlton ?W5 ?King ?Offsite
14. Please specify exact location of placement, including unit or clinic name, and if inpatient, outpatient or both.
15. Does this clinical area utilize Dovetale? ? Yes ? No
16. If yes does the learner require ? Clinical Documentation ? Scheduling ? Chart Access
17. Is the placement for research? ?Yes ?No
a. If yes, is the Research Institute aware of the placement and has their paperwork been completed to register the student with them? ?Yes ?No
b. If no, what is the reason for not involving the research institute?
Please forward completed form to below.
Thank you,
Peggy Bosanac, PT
Academic Placement Coordinator for Health Professionals with the exception of Physicians and Nurses
905-522-1155 Ext 32264
Fax: 905-521-6135
pbosanac@stjoes.ca
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