LHSC Student Registration Form

Thank you for completing the on-line orientation program. It has provided you with important information pertaining to your non-medical student experience at London Health Sciences Centre. Please ensure that you have reviewed the orientation modules carefully, as it is expected that you will know the information for your time spent at LHSC. It is also expected that you will remain up to date on policies and procedures while on-site at LHSC.

By submitting this registration form, you verify that you have completed the orientation modules, you receive credit for completing the on-line orientation program, and you complete your registration with Student Affairs, which is required in order for you to be a non-medical student on-site at London Health Sciences Centre.

Note: Do not enter a username or password into the login information to the right. This is for Student Affairs' use only.

Personal information on this form is collected under the authority of the Public Hospitals Act, Reg. 965, and will be used for the purposes of student placement and to facilitate compliance with public hospitals' legislated accountabilities at London Health Sciences Centre. Questions about this collection should be directed to Student Affairs, 750 Baseline Road, Suite 201, London, Ontario, Canada N6C 2R6, 519-685-8500 extension 76500, www.lhsc.on.ca, Student_Affairs@lhsc.on.ca.

PART 1: Personal Information

Role:

First Name:

Last Name:

Institution (*High School Co-op- select your school board):

Academic Program :

Other-Non-clinical, please specify:

Other Clinical, please specify:

Year in Program:

Student Credentials upon Academic Program completion:

PART 2: Placement Information

Unit:

Site:

LHSC Student Placement Supervisor/Preceptor First Name:

LHSC Student Placement Supervisor/Preceptor Last Name:

LHSC Student Placement Supervisor/Preceptor Title:

LHSC Student Placement Supervisor/Preceptor Telephone Extension:

Start date of placement:

End date of placement:

Total hours of placement:

PART 3: School/Corporation Contact Information (enter 'not applicable' if this experience is NOT practicum/co-op/thesis/project work for your academic/training program)

School Contact First Name:

School Contact Last Name:

School Contact Title:

School Contact Email Address:

PART 4: Additional Information

Student's Email Address (one you check regularly):

Nature of Unpaid Student Placement:

Conditions of Unpaid Placement

PART 5: IV Direct Administration – IP Students Only

IV Direct Link

IP students are required to complete the Intravenous Direct Administration module.

Acknowledgement

PART 6: Panic Alarms

Panic Alarm Link

Student Affairs requires students within the organization to complete the Panic Alarm module.

Acknowledgement

PART 7: Online Training Modules

Online training

The LHSC online orientation and training modules provide important information for your student placement and are a mandatory requirement to be on site at London Health Sciences Centre.

Acknowledgement

PART 8: Young Workers

Young Workers Link

Students under the age of 25 must verify that they have read and understand safe work policies, measures and procedures specific to the workplace and the duties they will perform during their placement at LHSC. Please refer to https://www.lhsc.on.ca/doc/orientation/act/story.html

Acknowledgement

PART 9: Privacy and Confidentiality

Privacy Statement I confirm that I have completed LHSC’s online Privacy and Confidentiality Education Program and that I understand my responsibilities for the confidentiality and security of patient information. I commit to:• respect patients’ right to privacy,• keep patient information entrusted to me as confidential and secure regardless of the format of the information • access, use and disclose only the patient information needed to fulfill my student placement • ensure the confidentiality and security of logins to patient care systems as well as other hospital systems to reduce risk of unauthorized access or use • also hold in confidence staff and affiliate information as well as the confidential business information of the organization• be familiar with and comply with LHSC’s policies and procedures regarding privacy, confidentiality and security of confidential information• immediately notify the LHSC Privacy Office if I become aware of a potential or actual privacy or security breach of confidential information• maintain my obligations related to privacy, confidentiality and security of confidential information even after my LHSC student placement endsI understand that I may consult my LHSC Student Supervisor/Preceptor or the LHSC Privacy Office for questions regarding my privacy, confidentiality and information security responsibilities. I understand that any unauthorized access to, use of, disclosure of, or failure to safeguard patient information, or the confidential information of staff and affiliates or the confidential business information of the organization may result in action, up to and including termination of my student placement at LHSC.

Acknowledgement

PART 10: Accommodation Needs

Select one option below

PART 11: Declaration

E-Signature The E-Signature will have the same binding effect as an original signature