Student & Preceptor Information
Please complete the form and click on Submit.
Please note that your preceptor information must be accurate including email address and a telephone number where your preceptor can be reached.
If you have any technical difficulties accessing or submitting this form, please email it.nursing@utoronto.ca.
Any other questions related to this form should be sent to Kong Ng at nursingplacementoffice@utoronto.ca.
* Indicates a required field
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Notice of Collection of 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 is 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
Data Collected
The following data is collected on this form:
* Indicates a required field
Academic Year* (system provided field)
Date and Time of form submission* (system provided field)
Personal Information Collection Consent.* See Personal Information Statement tab (No, or Yes, I agree with the statement). If you select No, you will not be able to continue with the application and you can discuss your options by contacting Kong Ng at nursingplacementoffice@utoronto.ca.
PERSONAL INFORMATION
Student First Name*
Student Last Name*
Student Number*
Student Email & Email Confirmation*
Current Course* (Select your course as registered in ACORN from the drop down table provided)
PRECEPTOR(S) INFORMATION
Preceptor First Name*
Preceptor Last Name*
Preceptor Telephone Number*
Preceptor Email Address*
Placement Site (Hospital/Agency)*
Department/Unit E.g., Law and Mental Health; if you are at an agency other than a hospital, please indicate ‘Community Health’ unless there is an area listed*
Indicate Days of the Week and Clinical Hours per Clinical Day/Shift*
Secondary Preceptor First Name (Optional Filed)
Secondary Preceptor Last Name* (Mandatory field if Preceptor First Name is entered otherwise this is optional)
Secondary Preceptor Telephone Number* (Mandatory field if Preceptor First Name is entered otherwise this is optional)
Secondary Preceptor Email Address* (Mandatory field if Preceptor First Name is entered otherwise this is optional)
Secondary Preceptor Placement Site (Hospital/Agency)* (Mandatory field if Preceptor First Name is entered otherwise this is optional)
Secondary Preceptor Department/Unit E.g., Law and Mental Health; if you are at an agency other than a hospital, please indicate ‘Community Health’ unless there is an area listed.* (Mandatory field if Preceptor First Name is entered otherwise this is optional)
Secondary Preceptor – Indicate Days of the Week and Clinical Hours per Clinical Day/Shift* (Mandatory field if Preceptor First Name is entered otherwise this is optional)
ADDITIONAL INFORMATION
Additional Information that you would like to share (max 150 characters)
Other Data Collected
This data is automatically collected by the system for the purpose of Information Technology administration and trouble shooting, as may be required and for summary-level only website statistical reporting:
Browser Type
Browser Version
IP Address (does not identify you)
Hardware and operating system (reported on an aggregate level)
Country/city of origin (reported on an aggregate level)
Session duration (reported on an aggregate level)