Lawrence S. Bloomberg Faculty of Nursing

Back Up CI Contracts

Form

Personal Information Statement

• Please note that backup CI coverage cannot occur unless all required documents are completed and returned to the Faculty of Nursing as well as full clearance has been given to work on site by the hospital/agency.

  • Personal Information Statement - It is a University of Toronto requirement to get consent for data collection on electronic forms.*
    Please see Personal Information Statement Tab and provide your data collection consent below.
    • No
    • Yes, I agree
  • You will not be able to continue with your submission. Please contact Kong Ng at kong.ng@utoronto.ca to discuss your options.
  • Name*
    First Last
  • Years of Nursing Experience*
    Please enter a number from 0 to 99.
  • BScN (Y/N)*
    A BScN degree is required.
    • Y
    • N
  • It is a requirement for Clinical Instructors to possess a minimum BScN education. Unfortunately we will not be able to consider candidates without a BScN degree.
  • Master’s Degree (Y/N)*
    • Y
    • N
  • CNO Registration Number*
  • Phone Number*
  • Email*
    Enter Email Confirm Email
  • Mailing address street name and number*
  • Mailing address city and province*
  • Mailing address postal code*
  • Current Workplace and Unit*
  • Other locations where you can provide backup
    e.g. previous employer (agency name and unit)
  • Area of Clinical Expertise*
  • Are you currently enrolled at UofT as an MN/Post-Master’s NP or PhD student?*
    (if you completed your studies in June and have not convocated, please indicate "yes")
    • Yes
    • No
  • If known, indicate the date of the first day working as a backup CI.
    MM slash DD slash YYYY
  • Returning Clinical Instructor*
    • Yes
    • No

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  PERSONAL INFORMATION

  The University of Toronto respects your privacy. The information on this form is collected pursuant to section 2(14) of the University of Toronto Act, 1971. It is collected for the purpose of administering admission, registration, academic programs, university-related student activities, activities of student societies, financial assistance and awards, graduation and university advancement, and for the purpose of statistical reporting to government agencies. Your IP address and browser version are collected for the purpose of Information Technology troubleshooting, as may be required. At all times, all data is protected in accordance with the Freedom of Information and Protection of Privacy Act. If you have questions, please refer to www.utoronto.ca/privacy OR contact the University’s Freedom of Information and Protection of Privacy Office at 416 946-5835, Room 104, McMurrich Bldg., 12 Queen’s Park Crescent West, Toronto, ON, M5S 1A8.

  I agree to have the information in this form plus my IP address and browser version be collected and stored electronically and I understand it will be protected in accordance with the Freedom of Information and Protection of Privacy Act. I understand that the information will be shared and viewed only by those who need to know. I also understand this form will be retained based on the University’s best practice guidelines for records retention, after which it will be destroyed in accordance with Information Technology Security best practices.